Form Cms-821 - Peritoneal Dialysis Clinical Performance Measures Data Collection - 2005 Page 2
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PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 (CONTINUED)
18. ANEMIA MANAGEMENT: For each lab question below, enter the first lab value obtained for each two-month time
period: OCT-NOV 2004, DEC 2004-JAN 2005, FEB-MAR 2005. Include the date each lab was drawn. Enter NF/NP if the
lab value cannot be located.
OCT-NOV 2004
DEC 2004-JAN 2005
FEB-MAR 2005
A. First laboratory hemoglobin (Hgb) during
____ ____ . ____ g/dL
____ ____ . ____ g/dL
____ ____ . ____ g/dL
the two-month time period (If NF/NP go to 18C) Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
B.1.a. Did the patient have a prescription for Epoetin
Epoetin:
Epoetin:
Epoetin:
at anytime during the 28 days before the Hgb in
Yes
No
Yes
No
Yes
No
18A was drawn?
Unknown
Unknown
Unknown
Did the patient have a prescription for
B.1.b.
Darbepoetin:
Darbepoetin:
Darbepoetin:
Darbepoetin (Aranesp™) at anytime during the
Yes
No
Yes
No
Yes
No
28 days before the Hgb in 18A was drawn?
Unknown
Unknown
Unknown
B.2.a. What was the TOTAL PRESCRIBED Epoetin
Epoetin:
Epoetin:
Epoetin:
dose in effect prior to the 28 days BEFORE
__________ units/28 days
__________units/28 days
__________ units/28 days
the Hgb in 18A was drawn?
(Instructions on page 5)
B.2.b.What was the TOTAL PRESCRIBED Darbepoetin
Darbepoetin:
Darbepoetin:
Darbepoetin:
dose in effect prior to the 28 days BEFORE the
__________ mcg/28 days
__________ mcg/28 days
__________ mcg/28 days
Hgb in 18A was drawn?
(Instructions on page 5)
B.3.a. How many doses per
(28 days) of
month
Epoetin:
Epoetin:
Epoetin:
Epoetin was prescribed?
__________ per 28 days
__________ per 28 days
__________ per 28 days
B.3.b. How many doses per month (28 days) of
Darbepoetin:
Darbepoetin:
Darbepoetin:
Darbepoetin was prescribed?
__________ per 28 days
__________ per 28 days
__________ per 28 days
B.4.a. What was the prescribed route of admini-
Epoetin:
Epoetin:
Epoetin:
stration for Epoetin? (Check all that apply)
IV
SC
Unknown
IV
SC
Unknown
IV
SC
Unknown
What was the prescribed route of admini-
B.4.b.
Darbepoetin:
Darbepoetin:
Darbepoetin:
stration for Darbepoetin? (Check all that apply)
IV
SC
Unknown
IV
SC
Unknown
IV
SC
Unknown
C. First serum ferritin concentration during the
___ ___ ___ ___ ng/mL ___ ___ ___ ___ ng/mL ___ ___ ___ ___ ng/mL
two-month time period:
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
D. First % transferrin saturation (TSAT) during the
_____ _____ _____ %
_____ _____ _____ %
_____ _____ _____ %
two-month time period:
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
E. Was iron prescribed at any time during the two-
Yes
No (go to 19)
Yes
No (go to 19)
Yes
No (go to 19)
month time period?
(go to 19)
(go to 19)
(go to 19)
Unknown
Unknown
Unknown
F. If yes, what was the prescribed route of iron
IV
PO
IV
PO
IV
PO
administration? (Check all that apply).
Unknown
Unknown
Unknown
G. If the patient was prescribed IV iron, what was
the total dose of IV iron administered during the
two-month time period?
____________ mg
_____________ mg
_____________ mg
19. SERUM ALBUMIN: Enter the first serum albumin obtained for each two-month time period: OCT-NOV 2004, DEC
2004-JAN 2005, FEB-MAR 2005. Include the date the serum albumin was drawn. Enter NF/NP if the lab value cannot be
located. Check the method used (BCG/bromcresol green or BCP/bromcresol purple) by the lab to determine serum albu-
min. If lab method unknown, call lab to find out.
OCT-NOV 2004
DEC 2004-JAN 2005
FEB-MAR 2005
A. First serum albumin during the two-month
______ . ______ g/dL
______ . ______ g/dL
______ . ______ g/dL
time period:
Date: ____/____/____
Date: ____/____/____
Date: ____/____/____
B. Check lab method used: BCG = bromcresol green
BCP = bromcresol purple
BCG
BCP
BCG
BCP
BCG
BCP
20. PERITONEAL DIALYSIS ADEQUACY: The remainder of this form lists a series of questions regarding adequacy
measurements for this patient. Please answer questions 20A and B FOR EACH TWO-MONTH TIME PERIOD indi-
cated. Then continue to pages 3 and 4.
OCT-NOV 2004
DEC 2004-JAN 2005
FEB-MAR 2005
A. Was the patient on peritoneal dialysis at any time
Yes
No
Yes
No
Yes
No
during this period?
Unknown
Unknown
Unknown
B. Was the patient on hemodialysis or did patient
Yes
No
Yes
No
Yes
No
receive a transplant at any time during this period?
Unknown
Unknown
Unknown
CMS – 821 (Rev.1/20/05)
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