CMS-10432 Transition Record Measures

Form Approved
OMB No. 0938-1171
Expires: TBD

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program
Online Data Entry Tool Content for Web-Based 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

Transition Record

Transition Record with Specified Elements Received by Discharged Patients (Discharges from an Inpatient
Facility to Home/Self Care or Any Other Site of Care)
NUMERATOR

CY 2016

Patients or their caregiver(s) who received a transition record
(and with whom a review of all included information was documented)
at the time of discharge including, at a minimum, all of the following elements:
Inpatient Care
• Reason for inpatient admission, AND
• Major procedures and tests performed during inpatient stay and summary of results, AND
• Principal diagnosis at discharge
Post-Discharge/ Patient Self-Management
• Current medication list, AND
• Studies pending at discharge (e.g., laboratory, radiological), AND
• Patient instructions
Advance Care Plan
• Advance directives or surrogate decision maker documented OR
• Documented reason for not providing advance care plan
Contact Information/Plan for Follow-up Care
• 24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND
• Contact information for obtaining results of studies pending at discharge, AND
• Plan for follow-up care, AND
• Primary physician, other health care professional, or site designated for follow-up care
DENOMINATOR

CY 2016

All patients, regardless of age, discharged from an inpatient facility
to home/self care or any other site of care

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 Web-Based Measure Collection
FY 2018 and Subsequent Years

CCN

Facility Name

Transition Record
Timely Transmission of Transition Record (Discharges from an Inpatient Facility to Home/Self Care or Any
Other Site of Care)
NUMERATOR

CY 2016

Patients for whom a transition record was transmitted to
the facility or primary physician or other health care professional
designated for follow-up care within 24 hours of discharge
DENOMINATOR

CY 2016

All patients, regardless of age, discharged from an
inpatient facility (e.g., hospital inpatient or observation,
skilled nursing facility, or rehabilitation facility) to home/self care or
any other site of care

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,
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 Web-Based Measure Collection
FY 2018 and Subsequent Years
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