CMS-10432 TOB & IMM Measures

Inpatient Psychiatric Facility Quality Reporting Program (CMS-10432)

TOB & IMM 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 Web-Based Measure Collection

FY 2017 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

Tobacco Treatment


Tobacco Treatment- TOB-1 Tobacco Use Screening

NUMERATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

TShape5 Shape4 Shape6 Shape3 he total number of patients who were screened for
tobacco use status within the first three days of admission


DENOMINATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

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





Tobacco Treatment- TOB-2 Tobacco Use Treatment Provided or Offered

TOB-2

NUMERATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

TShape11 Shape12 Shape13 Shape14 he number of patients who received or refused practical
counseling to quit AND received or refused FDA
approved cessation medications during the first three days
after admission


DENOMINATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

TShape18 Shape17 Shape16 Shape15 he number of hospitalized inpatients 18 years of age and
older identified as current tobacco users





Tobacco Treatment TOB-2a

NUMERATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

TShape22 Shape21 Shape20 Shape19 he number of patients who received practical counseling
to quit AND received FDA-approved cessation
medications during the first three days after admission


DENOMINATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

TShape23 Shape24 Shape25 Shape26 he number of hospitalized inpatients 18 years of age and
older identified as current tobacco users




Immunization


Immunization IMM-2 Influenza Immunization

NUMERATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

TShape27 Shape28 Shape29 Shape30 he number of inpatient discharges who were screened
for influenza vaccine status and were vaccinated prior
to discharge if indicated


DENOMINATOR 1Q 2015 2Q 2015 3Q 2015 4Q 2015

TShape31 Shape32 Shape33 Shape34 he number of acute care hospitalized inpatients age
6 months and older discharged during October, November,
December, January, February, or March


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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