Hospital Name

Quality Core Measure Checklist

Criteria Met
Y/ N/ NA

ACUTE MYOCARDIAL INFARCTION (AMI)

Aspirin received within 24 hours prior to or after hospital arrival
Contraindications documented if not given?
Beta Blocker received within 24 hours after arrival
Contraindications documented if not given?
Primary PCI within 90 minutes of arrival
Fibrinolytic Therapy within 30 minutes of arrival
Adult Smoking Cessation advice or counseling documented during this hospital stay (If patient
smoked cigarettes anytime in past year)
ACEI or ARB prescribed at discharge for EF less than 40% and/or moderate to severe LV systolic
dysfunction
Contraindications for both ACEI and ARB documented if not given?
Aspirin prescribed at discharge
Contraindicatons documented if not given?
Beta Blocker prescribed at discharge
Contraindications documented if not given?

Hospital Name
Quality Core Measure Checklist
Criteria Met
Y/ N/ NA

CONGESTIVE HEART FAILURE (HF)

Assessment of LVF before arrival, during hospitalization, or planned for after discharge
ACEI or ARB prescribed for EF less than 40% and/or moderate to severe LV systolic dysfunction at
discharge
Contraindications for both ACEI and ARB documented if not given?
Adult Smoking Cessation advice or counseling documented during this hospital stay (If patient
smoked cigarettes anytime in past year)
* Discharge Instructions address activity level
* Discharge Instructions address diet
* Discharge Instructions address follow-up appointment
* Discharge Instructions address medications (All discharge medications prescribed at discharge
must be listed on the discharge instruction sheet given to patient or caregiver and must match
physician medication documentation)
* Discharge Instructions address what to do if symptoms worsen
* Discharge Instructions address weight monitoring

Patient Information

G:/QSS/CoreMeasures/CoreMeasuresChecklist

Not part of the permanent record

Revised 7/14/2008

G:/QSS/CoreMeasures/CoreMeasuresChecklist

Hospital Name
Concurrent Core Measure Checklist
Criteria Met

PNEUMONIA (PN)

Y/ N/ NA

Positive Chest x-ray for pneumonia, consolidates, infiltrates? If no, stop

abstraction
Admit date/time________________ ______________
ED Admit / Direct Admit
Blood cultures (initial hospital specimen) collected prior to first antibiotic
received in ER
Antibiotic within 6 hours of Hospital arrival
Adult Smoking Cessation advice or counseling documented during this hospital stay
(If patient smoked cigarettes anytime in past year)
Pneumococcal vaccine for eligible patients age 65 or older or if other criteria is
met.
Influenza vaccine for eligible patients age 50 or older, discharged in the months
October through March

Patient Sticker

Not part of the permanent record

Revised 7/14/2008