Form Cms-821 - Peritoneal Dialysis Clinical Performance Measures Data Collection - 2005
ADVERTISEMENT
1
2
3
4
5
6PERITONEAL DIALYSIS CLINICAL PERFORMANCE
MEASURES DATA COLLECTION FORM 2005
[Before completing please read instructions at the bottom of this page and on pages 5 and 6]
PATIENT IDENTIFICATION
MAKE CORRECTIONS TO PATIENT INFORMATION
ON LABEL IN THE SPACE BELOW
Place Patient Data Label Here
12. If this patient is unknown or was not dialyzed in the facility at any time during OCT 2004-MAR 2005 return the blank
form to the Network.
13. Patient's Ethnicity (Check appropriate box).
non-Hispanic
Hispanic, Mexican American (Chicano)
Hispanic, Puerto Rican
Hispanic, Cuban American
Hispanic, Other
Unknown
.
14a.Patient’s height (MUST COMPLETE): _________inches OR _________centimeters
( only for patients < 18 years old, provide date when height was measured:
)
____ / ___ / _____
(mm) (dd) (yyyy)
14b.Patient’s weight (abdomen empty) (first clinic visit weight after Oct. 1, 2004): _______ . ___lbs. OR ______ . ___ kg.
15. Did patient have limb amputation(s) prior to Mar. 31, 2005:
Yes
No
Unknown
16. Has the patient ever been diagnosed with any type of diabetes?
Yes (go to 17)
No (go to 18)
Unknown (go to 18)
17.
If question 16 was answered YES, was the patient taking medications to control the diabetes during the study period?
Yes
No
Unknown If YES, was the patient using insulin during the study period?
Yes
No
Unknown
Individual Completing Form (Please print):
First name: ___________________________ Last name: ____________________________________ Title: _______________
Phone number: (_______) _________ - __________
Fax number: (_______) _________ - ____________
INSTRUCTIONS FOR COMPLETING THE PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005
The label on the top left side of this form contains the following patient identifying information (#’s 1-11). If the information is
incorrect make corrections to the right of the label.
1. LAST and first name.
2. DATE of birth (DOB) as MM/DD/YYYY.
3. SOCIAL Security Number (SSN).
4. HEALTH Insurance Claim Number (HIC), (same as Medicare number).
5. GENDER (1=Male; 2=Female).
6. RACE (1=American Indian/Alaska Native; 2=Asian; 3=Black; 4=White;
7. PRIMARY cause of renal failure by
5=Unknown; 6=Pacific Islander; 7=Mid East Arabian; 8=Indian Subconti-
CMS-2728 code.
nent; 9=Other/Multiracial).
9. ESRD Network number.
8. DATE, as MM/DD/YYYY, that the patient began a regular course of dialysis.
Do not make corrections to this item.
10. Facility’s Medicare provider number.
11. The most RECENT date this patient returned to peritoneal dialysis following:
transplant failure, an episode of regained kidney function, or switched modality.
12. If the patient is unknown or if the patient was not dialyzed in the facility at any time during OCT 2004 through MAR 2005,
send the blank form back to the ESRD Network office. Provide the name and address of the facility providing services to
this patient on December 31, 2004, if known.
13. Patient’s Ethnicity. Please verify the patient’s ethnicity with the patient and check appropriate box.
14a.Enter the patient’s height in inches or centimeters. HEIGHT MUST BE ENTERED, do not leave this field blank. You may ask
the patient his/her height to obtain this information. If the patient had both legs amputated, record pre-amputation height and
check YES for item 15.
14b.Enter the patient’s weight (abdomen empty) in pounds or kilograms. Use the FIRST CLINIC VISIT weight on or after
October 1, 2004.
15. For the purpose of this study, check NO if this patient has had toe(s), finger(s), or mid-foot (Symes) amputation; but check
YES if this patient has had a below-knee, below-elbow, or more proximal (extensive) amputation prior to Mar. 31, 2005.
16. Check either “Yes”, “No”, or “Unknown” to indicate if the patient has ever been diagnosed with any type of diabetes. If
YES, proceed to question 17.
17.
Check either “Yes”, “No”,
or “Unknown”
to indicate if the patient was taking medications to control the diabetes during the study
period. If the answer to 17 is YES, please check either “Yes”, “No”,
or “Unknown”
to indicate if the patient was using insulin during
the study period. Study period is OCT 2004 -MAR 2005.
P
I
18
24
P
2, 3,
4
.
LEASE COMPLETE
TEMS
THROUGH
ON
AGE
AND
OF THIS DATA COLLECTION FORM
I
5
6.
NSTRUCTIONS FOR COMPLETING THESE ITEMS ARE ON PAGES
AND
CMS – 821 (Rev.1/20/05)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical