CMS-10432 SUB-1 Measure

Inpatient Psychiatric Facility Quality Reporting Program (CMS-10432)

SUB-1 collection form

Inpatient Psychiatric Facility Quality Reporting Program

OMB: 0938-1171

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Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Substance Use Measure Collection

FY 2016 and Subsequent Years

IPFs should complete the form in a fillable PDF format and submit via email to:
[email protected].

CShape1 Shape2 CN Hospital Name


Substance Use- SUB -1 Alcohol Use Screening

NUMERATOR 1Q 2014 2Q 2014 3Q 2014 4Q 2014

TShape3 Shape4 Shape5 Shape6 he number of patients who were screened for alcohol use
using a validated screening questionnaire for unhealthy
drinking within the first three days of admission


DENOMINATOR 1Q 2014 2Q 2014 3Q 2014 4Q 2014

TShape10 Shape9 Shape8 Shape7 he number of hospitalized inpatients 18 years of age and
older


PRA DISCLOSURE STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1171. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleInpatient Psychiatric Facility Quality Reporting (IPFQR) Program Online Data Entry Tool Content for Web-Based Measure Collection
SubjectInpatient Psychiatric Facility Quality Reporting (IPFQR) Program Online Data Entry Tool Content for Web-Based Measure Collection
AuthorCMS
File Modified0000-00-00
File Created2021-01-27

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