Form 57.700 Reporting Plan Glycemic Control Module Hypoglycemia

Form Approved

OMB No. 0920-0666

Exp. Date:  12/31/2026

www.cdc.gov/nhsn

Medication Safety- Digital Measure Reporting Plan (CDC57.700)

Page 1 of 1

*required for saving

Facility ID: _____________

Measure

Glycemic Control Module

Glycemic Control: Measure data are collected by facility and include all inpatient locations, emergency departments, 24-hour observation units, and IRF/IPF locations.

Hypoglycemia (HYPO)

Measure HYPO

Following ☐

Start Month*

Start Year*

End Month

End Year

Hyperglycemia (HYPER)

Measure HYPER

Following ☐

Start Month*

Start Year*

End Month

End Year

Hospital-onset Acute Kidney Injury (HAKI) Module

HAKI: Acute Kidney Injury Measure data are collected by facility and include all inpatient locations, emergency departments, and 24-hour observation units.

Measure HAKI

Following ☐

Start Month*

Start Year*

End Month

End Year

Opioid Related Adverse Event (ORAE) Module

ORAE: Opioid Related Adverse Event Measure data are collected by facility and include all inpatient locations, emergency departments, and 24-hour observation units.

Measure ORAE

Following ☐

Start Month*

Start Year*

End Month

End Year

Notes: During the specified reporting period, the facility authorizes NHSN to query your facility’s FHIR server to collect the specified data elements as per the NHSN Medication Safety Component (MSC) Digital Quality Measure (dQM) protocols for each of the modules that appear on this form. The data collected will be used to provide measure specific event rates for each measure followed, as well as additional analytic and reporting options (for example, line-level lists).

• To participate in any of the NHSN MSC dQM modules, a Medication Safety Annual Survey must be completed and submitted. The survey must be completed annually and submitted by the end of February. This will allow addition of reporting plans for the current year. Data will only be pulled when there is a completed annual survey.

• Completion of the reporting plan indicates that data transmitted by your facility conforms to the NHSN dQM protocol(s) for the measures your facility elected to follow and instructions for reporting FHIR dQMs to NHSN. This includes adherence to technical specifications for value sets (i.e., local or non-standardized codes are mapped to established value sets such as RxNorm, LOINC, and HSLOC).

Assurance of Confidentiality:  The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-0666).

CDC 57.700(Front) Rev. 5, v9.2

CDC 57.700 (Back) Rev. 5, 9.2