CMS-10432 EHR & Patient Exp of Care Measures

Form Approved
OMB No. 0938-1171
Expires: TBD

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Structural Measures
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

Measure: Assessment of Patient Experience of Care
Does the facility complete a detailed assessment of patient experience of care using a standardized
collection protocol and structural instrument?

Yes

No

If yes, please specify the name of the survey administered.

03/2015

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Form Approved
OMB No. 0938-1171
Expires: TBD

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Structural Measures
FY 2018 and Subsequent Years
Measure: Use of an Electronic Health Record
Please select which of the following statements best describes the facility’s highest level typical use
of an Electronic Health Record system (excluding the billing system) during the reporting period,
and whether this use includes the exchange of interoperable health information with a health
information service provider:
a. The facility most commonly used paper documents and other forms of information
exchange (e.g. email) NOT involving transfer of health information using EHR
technology at times of transition in care.
b. The facility most commonly exchanged health information using non-certified EHR
technology (i.e. not certified under the ONC HIT Certification Program) at times of
transition in care.
c. The facility most commonly exchanged health information using certified EHR

technology (certified under ONC HIT Certification Program) at times of transition in
care.
Please indicate whether transfers of health information at times of transition in care include the
exchange of interoperable health information with a health information service provider (HISP):
Yes

No

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

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