Diko : en:documentation of medical reason(s) for not including documentation that follow up imaging is not needed (e.g., patient has multiple endocrine neoplasia, patient has cervical lymphadenopathy, other medical reason(s))

en:documentation of medical reason(s) for not including documentation that follow up imaging is not needed (e.g., patient has multiple endocrine neoplasia, patient has cervical lymphadenopathy, other medical reason(s))

Catégories

Nom

Informations lexicales

Langue:anglais

Liens externes

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umls:C4050182

Associations d'idées

[F]

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50+

en:advanced brain imaging (cta, ct, mra or mri) was not ordered

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en:antiretroviral therapy prescribed

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en:aspirin not prescribed for documented reasons (e.g., allergy, medical intolerance, history of bleed)

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en:chlamydia, gonorrhea, and syphilis not screened, due to documented reason (patient refusal is the only allowed exclusion)

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en:documentation of medical reason(s) for not completely infusing the prophylactic antibiotic prior to the inflation of the proximal tourniquet (e.g., a tourniquet was not used)

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en:documentation of medical reason(s) for not prescribing a beta-lactam antibiotic (e.g., allergy, intolerance to beta -lactam antibiotics)

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en:documentation of medical reason(s) for not reporting pt category and a statement on thickness and ulceration and for pt1, mitotic rate (e.g., negative skin biopsies in a patient with a history of melanoma or other documented medical reasons)

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en:documentation of negative or managed positive tb screen with further evidence that tb is not active

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en:documentation of order for first or second generation cephalosporin for antimicrobial prophylaxis

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en:documentation of patient pain brought to a comfortable level within 48 hours from initial assessment

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en:documentation of patient reason(s) for not referring to hospice care (e.g., patient declined, other patient reasons)

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en:documentation of patient stroke following cas

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en:documentation of patient-specific risk assessment with a risk calculator based on multi-institutional clinical data, the specific risk calculator used, and communication of risk assessment from risk calculator with the patient or family

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en:documentation of post-surgical anatomy (e.g., right hemicolectomy, ileocecal resection, etc.)

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en:documentation of reason for not detecting adenoma(s) or other neoplasm. (e.g., neoplasm detected is only diagnosed as traditional serrated adenoma, sessile serrated polyp, or sessile serrated adenoma

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en:documentation of screening for uterine malignancy or those that had an ultrasound and/or endometrial sampling of any kind

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en:documentation that patient is a current non-tobacco user

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en:documentation that the patient is not on daily aspirin or anti-platelet regimen

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en:documented re-assessment for the appropriateness of filter removal within 3 months of placement

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en:documented reason for not assessing hepatitis b virus (hbv) status (e.g. patient not receiving a first course of anti-tnf therapy, patient declined) within one year prior to first course of anti-tnf therapy

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en:door to puncture time of less than 2 hours

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en:elective delivery or early induction performed

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en:elective surgical procedure

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en:filter removed within 3 months of placement

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en:hepatitis c quantitative rna testing documented as performed between 4-12 weeks after the initiation of antiviral treatment

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en:i intend to report the general surgery measures group

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en:i intend to report the sinusitis measures group

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en:imaging study named according to standardized nomenclature

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en:intraoperative cystoscopy performed to evaluate for lower tract injury

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en:motor speech functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting

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en:no surgical site infection

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en:no unplanned hospital readmission within 30 days of principal procedure

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en:non small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as nsclc-nos with an explanation

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en:one high-risk medication not ordered

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en:operative report does not identify the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant, reason not given

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en:p2y inhibitor not prescribed at discharge

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en:patient achieved an improvement in visual acuity, from their preoperative level, within 90 days of surgery

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en:patient did not have at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits

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en:patient did not have one dose of meningococcal vaccine on or between the patient's 11th and 13th birthdays

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en:patient discharge to home no later than post-operative day #7

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en:patient had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits

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en: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

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en:patient not screened for uterine malignancy, or those that have not had an ultrasound and/or endometrial sampling of any kind, reason not given

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en:patient offered assistance with end of life issues during the measurement period

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en:patient received follow-up on the date of discharge or within 30 days after discharge

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en:patient received one-time screening for hcv infection

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en:patient sustained ureter injury at the time of surgery or discovered subsequently up to 1 month post-surgery

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en:patient underwent abdominal imaging with ultrasound, contrast enhanced ct or contrast mri for hcc

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en:patient was not referred to hospice care, reason not given

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en:patient who had a diagnosis of bipolar disorder or personality disorder, death, permanent nursing home resident or receiving hospice or palliative care any time during the measurement or assessment period

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50+