Medical History, including chief complaint; HPI; past, social & family 100% 100% 100% 100% hx., ROS, and physical exam w/in 24 32/32 25/25 25/25 82/82 hrs., conclusion and plan. Summary of patient’s psychosocial 94% 92% 92% 93% needs as appropriate to the patients * 30/32 23/25 23/25 76/82 Psychiatric Evaluation in patient’s 100% 100% 100% 100% record w/in 24 hrs. of admission 32/32 25/25 25/25 82/82 Psychiatric Evaluation authenticated 84% 92% 96% 90% within 60 hours of admission 27/32 23/25 24/25 74/82 91% 88% 88% 89% Physician (TO/VO w/in 72 hrs.) 162/179 142/161 135/154 439/494 93% 96% Evidence of appropriate informed 100% 96% 26/28 75/78 consent 25/25 24/25 4 declined 4 declined Clinical observations including the 100% 100% 100% 100% results of therapy. 32/32 25/25 25/25 82/82 Nursing discharge Progress Note with 100% 96% 100% 98% time of discharge departure 32/32 24/25 25/25 81/82 100% 100% 100% 100% Consultation reports, when applicable 10/10 9/9 10/10 29/29 22=N/A 16=N/A 15=N/A 53=N/A Advance Directive Status on admission and 94% 96% 98% 100% SW follow up after 30/32 25/25 80/82 25/25 Indicator and Rationale for Selection 1Q2017 2Q2017 3Q2017 4Q2017 YTD 100% 100% 100% 100% Notice of Privacy 32/32 25/25 25/25 82/82 Chart Completion w/in 30 days of discharge 97% 100% 100% 99% date/discharge summary completed within 30 31/32 25/25 25/25 81/82 days Discharge Packet sent to follow up 100% 84% 80% 89% provider within 5 days of discharge. 32/32 21/25 20/25 73/82
Medical History, including chief complaint; HPI; past, social & family hx., ROS, and physical exam w/in 24 hrs., conclusion and plan. 100% 32/32 100% 25/25 100% 25/25 100% 82/82 Summary of patient’s psychosocial needs as appropriate to the patients * 94% 30/32 92% 23/25 92% 23/25 93% 76/82 Psychiatric Evaluation in patient’s record w/in 24 hrs. of admission 100% 32/32 100% 25/25 100% 25/25 100% 82/82 Psychiatric Evaluation authenticated within 60 hours of admission 84% 27/32 92% 23/25 96% 24/25 90% 74/82 Physician (TO/VO w/in 72 hrs.) 91% 162/179 88% 142/161 88% 135/154 89% 439/494 Evidence of appropriate informed consent 93% 26/28 4 declined 100% 25/25 96% 24/25 96% 75/78 4 declined Clinical observations including the results of therapy. 100% 32/32 100% 25/25 100% 25/25 100% 82/82 Nursing discharge Progress Note with time of discharge departure 100% 32/32 96% 24/25 100% 25/25 98% 81/82 Consultation reports, when applicable 100% 10/10 22=N/A 100% 9/9 16=N/A 100% 10/10 15=N/A 100% 29/29 53=N/A Advance Directive Status on admission and SW follow up after 94% 30/32 96% 25/25 100% 25/25 98% 80/82 Indicator and Rationale for Selection 1Q2017 2Q2017 3Q2017 4Q2017 YTD Notice of Privacy 100% 32/32 100% 25/25 100% 25/25 100% 82/82 Chart Completion w/in 30 days of discharge date/discharge summary completed within 30 days 97% 31/32 100% 25/25 100% 25/25 99% 81/82 Discharge Packet sent to follow up provider within 5 days of discharge. 100% 32/32 84% 21/25 80% 20/25 89% 73/82
3Q2017.docx