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pdfForm Approved
OMB No. 0938-1171
Expires: TBD
Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Substance Use Measure Collection
FY 2018 and Subsequent Years
IPFs should complete the form in a fillable PDF format and submit via email to: [email protected].
CCN
Facility Name
Substance Use - SUB-1 Alcohol Use Screening
NUMERATOR
CY 2016
The 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
CY 2016
The number of hospitalized inpatients 18 years of age and
older
03/2015
Page 1 of 3
Form Approved
OMB No. 0938-1171
Expires: TBD
Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Substance Use Measure Collection
FY 2018 and Subsequent Years
IPFs should complete the form in a fillable PDF format and submit via email to: [email protected].
CCN
Facility Name
Substance Use - SUB-2 Alcohol Use Brief Intervention Provided or Offered
NUMERATOR
CY 2016
The number of patients who received or refused a brief intervention
DENOMINATOR
CY 2016
The number of hospitalized inpatients 18 years of age and older
who screen positive for unhealthy alcohol use or an alcohol use disorder
(alcohol abuse or alcohol dependence)
03/2015
Page 2 of 3
Form Approved
OMB No. 0938-1171
Expires: TBD
Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Substance Use Measure Collection
FY 2018 and Subsequent Years
IPFs should complete the form in a fillable PDF format and submit via email to:
[email protected].
CCN
Facility Name
Substance Use - SUB-2a Alcohol Use Brief Intervention
NUMERATOR
CY 2016
The number of patients who received a brief intervention
DENOMINATOR
CY 2016
The number of hospitalized inpatients 18 years of age and older
who screen positive for unhealthy alcohol use or an alcohol use disorder
(alcohol abuse or alcohol dependence)
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
03/2015
Page 3 of 3
| File Type | application/pdf |
| File Title | Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program Online Data Entry Tool Content for Web-Based Measure Collection |
| Subject | Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program Online Data Entry Tool Content for Web-Based Measure Collection |
| Author | CMS |
| File Modified | 2016-07-15 |
| File Created | 2016-07-15 |