Related Case Information
Service Date:
2024-11-11
Anesthesia ID:
h2
Service:
General Surgery
Age/Sex:
56 Male
Recorded By:
Tester, A
Report Date:
2024-11-11
Facility:
New York NY
Practice ID:
0
AQI #33
Unplanned Readmission
AQI #34
Surgical Site Infection
AQI #37
Unplanned Transfer or Admission
AQI #38
New Corneal Injury
MIPS #404
Anesthesiology Smoking Abstinence
MIPS #408
Opioid Therapy Follow-up
MIPS #412
Opioid Treatment Agreement
MIPS #414
Risk of Opioid Misuse
MIPS #424
Perioperative Temperature Management
MIPS #426
Transfer of Care to PACU
MIPS #427
Transfer of Care to ICU
MIPS #430
PONV—Adults
[AQI #33]
Unplanned Hospital Readmission within 30 days of Principal Procedure
Unplanned hospital readmission within 30 days of principal procedure
NO unplanned hospital readmission within 30 days of principal procedure
[AQI #34]
Surgical Site Infection
Surgical site infection
NO surgical site infection
[AQI #37]
Unplanned Transfer or Admission to Hospital
Elective surgery AND Patient did NOT have a documented planned stay prior to procedure AND Patient did NOT have an inpatient or under observational status at time of encounter AND Patient who was scheduled to be discharged from the facility on the same day as surgical procedure was performed experienced an unplanned hospital transfer or admission within 48 hours of the anesthesia service
Elective surgery AND Patient did NOT have a documented planned stay prior to procedure AND Patient did NOT have an inpatient or under observational status at time of encounter AND Patient did not experience an unplanned hospital transfer or admission within 48 hours of the anesthesia service
[AQI #38]
New Corneal Injury Not Diagnosed in the Postanesthesia Care Unit/Recovery Area after Anesthesia Care
Patient was NOT newly diagnosed with exposure keratitis or corneal abrasion in the postanesthesia care unit or recovery room
Patient diagnosed with new exposure keratitis or corneal abrasion in the postanesthesia care unit or recovery room
[MIPS #404]
Anesthesiology Smoking Abstinence– National Quality Strategy Domain: Effective Clinical Care
Current cigarette smokers AND Elective surgery AND Seen pre-operatively by anesthesiologist or proxy prior to the day of surgery AND Patients who abstained from smoking prior to anesthesia on the day of surgery or procedure
Current cigarette smokers AND Elective surgery AND Seen pre-operatively by anesthesiologist or proxy prior to the day of surgery AND Patients who did not abstain from smoking prior to anesthesia on the day of surgery or procedure
[MIPS #408]
Opioid Therapy Follow-up Evaluation– National Quality Strategy Domain: Effective Clinical Care
Patients prescribed opiates for longer than six weeks AND Patients who had a follow-up evaluation conducted at least every three months during opioid therapy
Patients prescribed opiates for longer than six weeks AND Patients who did not have a follow-up evaluation conducted at least every three months during opioid therapy
[MIPS #412]
Documentation of Signed Opioid Treatment Agreement– National Quality Strategy Domain: Effective Clinical Care
Patients prescribed opiates for longer than six weeks AND Documentation of signed opioid treatment agreement at least once during opioid therapy
Patients prescribed opiates for longer than six weeks AND No documentation of signed an opioid treatment agreement at least once during opioid therapy
[MIPS #414]
Evaluation or Interview for Risk of Opioid Misuse – National Quality Strategy Domain: Effective Clinical Care
Patients prescribed opiates for longer than six weeks AND Patient evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., Opioid Risk Tool, SOAAP-R) or patient interviewed at least once during opioid therapy
Patients prescribed opiates for longer than six weeks AND Patient not evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., Opioid Risk Tool, SOAAP-R) or patient not interviewed at least once during opioid therapy
[MIPS #424]
Perioperative Temperature Management – National Quality Strategy Domain: Patient Safety
Anesthesia of 60 minutes duration or longer AND At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time
Anesthesia of 60 minutes duration or longer AND Documentation of one of the following medical reason(s) for not achieving at least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time (e.g., Emergency cases, Intentional hypothermia, etc.)
Anesthesia of 60 minutes duration or longer AND At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time
Monitored Anesthesia Care (MAC)
[MIPS #426]
Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) – National Quality Strategy Domain: Communication and Care Coordination
Patient transferred directly from anesthetizing location to PACU AND A transfer of care protocol or handoff tool/checklist that includes the required key handoff elements is used
Patient transferred directly from anesthetizing location to PACU AND A transfer of care protocol or handoff tool/checklist that includes the required key handoff elements is not used
Transfer of care during an anesthetic or to the intensive care unit
[MIPS #427]
Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) – National Quality Strategy Domain: Communication and Care Coordination
Patient transferred directly from anesthetizing location to critical care unit AND Transfer of care checklist used
Patient transferred directly from anesthetizing location to critical care unit AND Transfer of care checklist not used
[MIPS #430]
Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy – National Quality Strategy Domain: Patient Safety
Patient received inhalational anesthetic agent AND Patient exhibits 3 or more risk factors for post-operative nausea and vomiting AND Patient received at least 2 prophylactic pharmacologic anti-emetic agents of different classes preoperatively and intraoperatively
Patient received inhalational anesthetic agent AND Patient exhibits 3 or more risk factors for post-operative nausea and vomiting AND Documentation of medical reason for not receiving at least 2 prophylactic pharmacologic anti-emetic agents of different classes preoperatively and intraoperatively (e.g., intolerance or other medical reason)
Patient received inhalational anesthetic agent AND Patient exhibits 3 or more risk factors for post-operative nausea and vomiting AND Patient did not receive at least 2 prophylactic pharmacologic anti-emetic agents of different classes preoperatively and intraoperatively
Record Measure
[Not part of patient's chart]
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