CMS-10432 Transitions Measures Collection Form

Data Collection Tool for Compliance with the Transition Record with Specified
Elements Received by Discharged Patients and Timely Transmission of Transition
Record Measures
This document is provided as an optional, informal mechanism to aid psychiatric facilities in the collection of information pertaining to
the Transition Record for Specified Elements Received by Discharged Patients and Timely Transmission of Transition Record
Measures. Data collected for these measures satisfy a requirement of the Inpatient Psychiatric Facility Quality Reporting (IPFQR)
Program under the Centers for Medicare & Medicaid Services (CMS). The tool is designed to collect data abstracted from the patient
medical record; however, once abstracted, the data will need to be compiled and reported to CMS in aggregate. It should be noted
that skip logic is not contained within the data collection paper tool. If there are any questions or concerns regarding the use of this
data collection paper tool, please contact the IPFQR Program Support Contractor at [email protected].
Transition Record with Specified Elements Received by Discharged Patients
The numerator is comprised of patients or their caregiver(s) who received a transition record (and with whom a review of all included
information was documented) at the tim
e of discharge. All 11 elements must be captured to satisfy the measure numerator.
The denominator includes all patients, regardless of age, discharged from the inpatient facility to home/self-care or any other site of
care. The measure excludes patients who died, left against medical advice (AMA), or discontinued care. Patients who discontinued
care include those who eloped or failed to return from leave, as defined in the notes below.
Topic

Inpatient Care

Are the following
elements included
in the transition
record?
Reason for IPF
admission

Element
Satisfied

Element Definition
Not
Satisfied
Documentation of the events the patient experienced prior to this
hospitalization; the reason for hospitalization may be a short
synopsis describing or listing the triggering or precipitating event. A
diagnosis alone is not sufficient.

Topic

Inpatient Care

Post-Discharge/
Patient SelfManagement
Post-Discharge/
Patient SelfManagement

Are the following
elements included
in the transition
record?
Major procedures
and tests, including
summary of results

Principal diagnosis
at discharge
Current Medication
List

Element
Satisfied

Element Definition
Not
Satisfied
All procedures and tests noteworthy in supporting patient
diagnosis, treatment, or discharge plan, as determined by provider
or facility. Examples may include complete blood count and
metabolic panel, urinalysis, and/or radiological imaging. Select Yes
in the Element Satisfied column if major procedures and tests are
in the transition record. If documentation exists in the transition
record indicating that no major procedures or tests were performed,
then select Yes in the Element Satisfied column.
Documentation indicating the final principal diagnosis at the time of
discharge.
The current medication list should include prescriptions, over-thecounter medications, and herbal products in the following
categories:
• Medications to be TAKEN by patient: Medications
prescribed prior to IPF stay to be continued after discharge
AND new medications started during the IPF stay to be
continued after discharge AND newly prescribed or
recommended medications to be taken after discharge.
Prescribed or recommended dosage, special
instructions/considerations, and intended duration must be
included for each continued and new medication listed. A
generalized statement regarding intended duration, such as
a blanket statement indicating that the patient should
continue the medications until told to stop, would be
acceptable for routine medications.
• Medications NOT to be taken by patient: Medications
(prescription, over-the-counter, and herbal products) taken
by the patient before the inpatient stay that should be
discontinued or withheld after discharge.

Topic

Post-Discharge/
Patient SelfManagement

Post-Discharge/
Patient SelfManagement

Are the following
elements included
in the transition
record?
Studies Pending at
Discharge (or
documentation that
no studies are
pending)
Patient Instructions

Element
Satisfied

Element Definition
Not
Satisfied
Medical tests not concluded at discharge. Examples include
complete blood count and metabolic panel, urinalysis, or
radiological imaging. Select Yes in the Element Satisfied column if
studies pending at discharge are in the transition record. If
documentation exists in the transition record, indicating that no
tests are pending at discharge, then select Yes in the Element
Satisfied column.
Directions for patient and/or caregiver to follow upon discharge
from the facility. Examples include medication information, dietary
or activity restrictions, warning signs and symptoms associated with
the condition, information regarding what to do if the patient
experiences a relapse of symptoms, etc. Instructions should be
appropriate for the patient, including the use of language services.

Topic

Advance Care
Plan

Are the following
elements included
in the transition
record?
Advance Directives
or surrogate
decision maker
documented OR
documented
reason for not
providing advance
care plan

Element
Satisfied

Element Definition
Not
Satisfied
A written, signed statement that details the patient’s preferences for
treatment should the patient be unable to make such decisions for
him/herself, whether that incapacitation be due to medical or
mental health reasons. The statement informs others about what
treatment the patient would or would not want to receive from
psychiatrists and/or other health professionals concerning both
psychiatric and non-psychiatric care. An Advance Directive
identifies the person to whom the patient has given the authority to
make decisions on his/her behalf, a surrogate decision maker.
Copies of the Advance Directive do not need to be transmitted to
the follow-up provider and the patient need not create an Advance
Directive(s) to satisfy this element. This element can be met if one
of the following is documented:
a.
The patient has an appointed surrogate decision maker.
b.
The patient has a non-psychiatric (medical) Advance Directive and
a psychiatric Advance Directive.
c.
If (a) or (b) was not met, the patient was offered information about
designating a surrogate decision maker or completing Advance
Directives, and if the criteria for (a) or (b) still were not met, a
reason was documented.
Advance Directives must be compliant with the state laws for the
state in which the patient receives care. Additional information on
the Advance Care Plan element can be found in the IPFQR
Program Manual at
http://www.qualityreportingcenter.com/inpatient/ipf/tools/.

Topic

Contact
Information/Plan
for Follow-Up
Care See
NOTES below.

Are the following
elements included
in the transition
record?
24-hour/7-day
contact information,
including physician
for emergencies
related to inpatient
stay

Contact
Information/Plan
for Follow-Up
Care See
NOTES below.

Contact information
for obtaining results
of studies pending
at discharge

Contact
Information/Plan
for Follow-Up
Care See
NOTES below.

Plan for follow-up
care

Element
Satisfied

Element Definition
Not
Satisfied
Physician, healthcare team member, or other healthcare personnel
who have access to medical records and other information
concerning the inpatient stay and who could be contacted
regarding emergencies related to the stay. 800 numbers, crisis
lines, or other general emergency contact numbers do not meet
this requirement unless personnel have access to the medical
records and other information concerning the inpatient stay.
Healthcare professional or facility contact number at which patient
can receive information on studies that were not concluded at
discharge. Patient preference should be considered in sharing
results of studies, including whether or not results should be
provided on paper. Select Yes in the Element Satisfied column if
contact information for obtaining results of studies pending at
discharge is in the transition record. If documentation exists in the
transition record indicating that no tests are pending at discharge,
then select Yes in the Element Satisfied column.
A plan for follow-up care that describes treatment and other
supportive services to maintain or optimize patient health. The plan
should include post-discharge therapy needed, any durable
medical equipment needed, family/psychosocial/outpatient
resources available for patient support, self-care instructions, etc.
The plan may also include other information, such as appointment
with outpatient clinician (if available), follow-up for medical issues,
social work and benefits follow-up, pending legal issues, and peer
support, e.g., Alcoholics Anonymous, Narcotics Anonymous, and/or
home-based services. The plan should be developed with
consideration to the patient’s goals of care and treatment
preferences.

Topic

Contact
Information/Plan
for Follow-Up
Care See
NOTES below.
Transition
Record with All
of the Specified
Elements
Transition
Record with All
of the Specified
Elements

Are the following
Element Element Definition
elements included
Satisfied
Not
in the transition
Satisfied
record?
Primary physician,
The primary care physician (PCP), medical specialist, psychiatrist
other healthcare
or psychologist, or other physician or healthcare professional who
professional, or site
will be responsible for appointments after inpatient visit. A site of
designated for
care may include a group practice specific to psychiatric care. A
follow-up care
hotline or general contact does not suffice for follow-up care.
Are ALL specified
elements included
in the transition
record?
Was the transition
record discussed
with the patient or
caregiver
OR
if the patient was
transferred to an
inpatient facility,
were the four
elements discussed
with the receiving
inpatient facility?
(See NOTES
below.)

Timely Transmission of Transition Record
The numerator includes patients for whom a transition record, as specified in the Transition Record with Specified Elements
Received by Discharged Patients Measure, was transmitted to the facility or primary physician, or other healthcare professional
designated for follow-up care within 24 hours of discharge. All 11 elements must be captured and transmitted within 24 hours to
satisfy the measure numerator.

The denominator includes all patients, regardless of age, discharged from an IPF to home/self-care, or any other site of care. The
measure excludes patients who died, left against medical advice (AMA), or discontinued care. Patients who discontinued care
include those who eloped or failed to return from leave.
Timely Transmission of Transition Record Data
Description
Date and time patient was discharged from the facility
Date and time transition record was transmitted
Method of transmission
(Mail, fax, secure e-mail, or hard copy provided to
transport personnel. If the follow-up healthcare
professional has mutual access to the electronic health
record (EHR), this must be documented as the
transmission method.)
Was transition record transmitted within 24 hours of
discharge
(Calculated as 24 consecutive hours or fewer from the
date and time of discharge to the date and time of
transmission.)

Data Element for Measure Calculation

Notes
A Transition Record is defined as a core, standardized set of data elements related to a patient’s demographics, diagnosis,
treatment, and care plan that is discussed with and provided to the patient/caregiver(s) in a printed or electronic format at each
transition of care and transmitted to the facility/physician/other healthcare professional providing follow-up care. The transition record
may only be provided in an electronic format if acceptable to the patient and only after all components have been discussed with the
patient.
To satisfy the numerator for both measures, this is what must occur:
For patients who are discharging to home, a transition record covering all 11 elements must be:
• Created;
• Discussed with the patient/caregiver;
• Provided to the patient/caregiver either in hard copy or electronically, if the patient agrees; and
• Transmitted to the next provider within 24 hours after discharge.

For patients who are discharging to an inpatient facility, a transition record covering all 11 elements must be:
Created;
Discussed with the receiving facility, but only highlighting these four elements:
o
24-hour/7-day contact information;
o
Contact information for pending studies;
o
Plan for follow-up care; and
o
Primary physician, other healthcare professional, or site designated for follow-up care; and
• Transmitted to the next provider within 24 hours after discharge.
•
•

The National Quality Forum (NQF) defines elopement as any situation in which an admitted patient leaves the healthcare facility
without staff’s knowledge.
A failure to return from leave occurs when a patient does not return at the previously agreed-upon date and time for continued
care. If the patient fails to return from leave, then the patient has left care without staff’s knowledge.

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 (current expiration: MM/DD/YYYY). The time required to complete this information collection is
estimated to average 15 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