CMS-10432 HBIPS Measures Data Collection Tool

Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

HBIPS Measures Data Collection Tool

Provider Name _________________________________________ CCN___________________
Address __________________________________________ Telephone ___________________
Submitter Name ____________________________________ Date Submitted_______________
Calendar year ___________
For Inpatient Psychiatric Facility Quality Reporting participating providers, responses are
required for all fields. If you have no data for any of the fields, then please enter zero. Do not
leave any fields blank.
Please follow the Joint Commission Specifications Manual for guidance on measure data
collection, exclusions, and population sampling.
IPFs should complete the form in a fillable PDF format and submit via email to:
[email protected].

Updated 03/2016

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Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program

HBIPS Measures Data Collection Tool
HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate
Justification
NUMERATOR

CY 2018

Please enter the number of psychiatric patients discharged
on two or more multiple antipsychotic medications
for each age group.

DENOMINATOR

CY 2018

Please enter the total number of psychiatric patients
discharged for each age group.

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 (Current expiration MM/DD/YYYY) . 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.

Updated 03/2016

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