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IN-CENTER HEMODIALYSIS (HD) CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 (CONTINUED)

18B.4: Check the appropriate box to indicate the prescribed route of administration for Epoetin or for Darbepoetin (intravenous

[IV] or subcutaneous [SC]). If the patient was prescribed Epoetin or Darbepoetin IV and SC during the month, please check

both boxes.

18C: Enter the patient’s 1st pre-dialysis serum ferritin concentration for each month OCT, NOV, DEC 2004. Include the date

the lab was drawn. If a serum ferritin concentration test was not found or not performed during the month, enter NF/NP.

18D: Enter the patient’s 1st pre-dialysis % transferrin saturation (TSAT) for each month OCT, NOV, DEC 2004. Include the

date the lab was drawn. If a % transferrin saturation (TSAT) test was not found or not performed during the month, enter

NF/NP.

18E: Check either “Yes”, “No”, or “Unknown” to indicate if iron was prescribed at any time during the months of OCT, NOV, and

DEC 2004. If there was no prescription for iron go to question 19.

18F: If the answer to 18E is “Yes”, please check the appropriate box to indicate the route of iron administration (intravenous

[IV] or by mouth [PO]) for OCT, NOV, and DEC 2004. If the patient received iron by mouth and IV during the month please

check both boxes.

18G:

If the patient was prescribed IV iron, add together all doses that were given during the month and enter the TOTAL dose of IV iron

(in mg) administered per month during OCT, NOV, and DEC 2004.

19A: Enter the patient’s 1st pre-dialysis serum albumin for each month OCT, NOV, DEC 2004. Include the date the lab was

drawn. If a serum albumin was not found or not performed during the month, enter NF/NP.

19B: Check the method used by the laboratory to determine the serum albumin value (bromcresol green or bromcresol purple). If

you do not know what method the laboratory used, call the lab to find out this information.

20A: Enter the number of times per week the patient was prescribed to receive dialysis in OCT, NOV, and DEC 2004. If the

prescription varied during a month, enter the prescription in effect the week prior to when the pre- and post-BUNs were

drawn. Do not leave this question blank.

20B: Enter the patient’s 1st URR recorded on the lab sheet for each month OCT, NOV, DEC 2004. Include the date the lab was

drawn. If not found or not performed during a month, enter NF/NP.

20C: Enter the patient’s 1st single-pool Kt/V recorded on the lab sheet for each month OCT, NOV, DEC 2004. Include the date

the lab was drawn. If not found or not performed during a month, enter NF/NP.

20D: Check the box to indicate the method used to calculate the single-pool Kt/V in 20C. If you do not know what method was

used, please ask the unit’s Medical Director. Please check the “Other” box if you do not use any of the methods

listed. If using another method and you know what it is, please write the method in the space provided.

20E: Check the appropriate box to indicate whether residual renal function was used to calculate the single-pool Kt/V in 20C. If

you do not know, please ask the unit’s Medical Director.

20F & G: Enter the patient’s 1st pre- and post-dialysis BUNs for each month. Include the dates the labs were drawn. Both the

pre- and post-dialysis BUN must be drawn on the same day. Enter NF/NP if not found or not performed during the month.

20H: Enter the patient’s pre- and post-dialysis weight at the dialysis session when the pre- and post-dialysis BUNs in question

20F&G were drawn. Circle either lbs or kgs as appropriate.

20I: Enter the patient’s total treatment time (actual delivered time) on dialysis during the session when the BUNs in question

20F&G were drawn for months OCT, NOV, DEC 2004. Do not enter the prescribed time on dialysis.

20J: Enter in mL/minutes the delivered blood pump flow rate (BFR) at 60 minutes after the start of the dialysis session or the

average delivered BFR when the BUNs in questions 20F&G were drawn for months OCT, NOV, DEC 2004. Do not enter the

prescribed blood pump flow rate or the highest achieved blood pump flow rate. Check the box to indicate which BFR is being

provided.

CMS – 820 (Rev.1/27/05)

Form Cms-820 - In-Center Hemodialysis (Hd) Clinical Performance Measures Data Collection - 2005 Page 5