Chronic kidney disease pim chart questions - American Board of Internal Medicine

Chronic kidney disease pim chart questions - American Board of Internal Medicine

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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses ABIM takes the protection of your patients' privacy very seriously. To that end, ABIM collects only the minimum amount of patient-level data necessary and has implemented HIPAA-compliant administrative, physical, and technical 1 N/A controls to protect the patient-level data both in transit and at rest. To further protect patient anonymity, please do not enter a patient's name (full or partial) or SSN in the Patient ID field. 2 Patient ID N/A NOTE: For the Patient Visit Date below, enter the most 3 N/A recent visit date. 4 Patient Visit Date N/A 5 Gender: [1] Male | [2] Female 6 Age at the most recent visit: N/A The following questions on patient characteristics are included to help the ABIM better understand the responses we receive from diplomates. In the future, the ABIM may 7 N/A use some of this information to provide targeted feedback, allowing diplomates to compare their performance with that of other physicians whose patient population is similar. Is the zip code of the patient's primary residence 8 [1] Yes | [2] No documented in the medical record? 9 5-digit zip code: N/A 10 Patient is Hispanic or of Latino origin or descent: [1] Yes | [2] No | [3] Unknown [1] White | [2] Black or African American | [3] Asian | [4] Native Hawaiian 11 Race (check all that apply): or other Pacific Islander | [5] American Indian or Alaska Native | [6] Other | [7] Unknown Page 1. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses Have language barriers significantly affected your ability to 12 [1] Yes | [2] No | [3] Don't know care for this patient? [1] Private insurance | [2] Traditional Medicare (Part B) | [3] Medicare Advantage/HMO (Part C) | [4] Medicare - type unknown | [5] What was the type of insurance or source of payment (not 13 Medicaid/SCHIP | [6] Worker's compensation | [7] VA, military, or other including co-payments) for this patient? Check all that apply. government | [8] Self-pay (not counting co-payment) | [9] No charge or charity care | [10] Other | [11] Unknown Has the patient's health insurance status (e.g., lack of insurance, high co-payment, high deductible, and/or 14 [1] Yes | [2] No substantial restrictions on coverage) significantly affected the choices of care you made for this patient? [1] Medication | [2] Diagnostic testing | [3] Behavioral services | [4] Other 15 What aspects of care have been affected? services 16 Length of your relationship with the patient: [1] Less than 12 months | [2] 12 months or longer 17 Physical Findings N/A [1] Yes, in pounds, measured at visit date above | [2] Yes, kilograms, Is the patient's most recent weight documented in the measured at visit date above | [3] Yes, in pounds, measured at a 18 medical record? previous visit | [4] Yes, in kilograms, measured at a previous visit | [5] No 19 Date of the most recent weight: N/A 20 Weight in pounds: N/A 21 Weight in kilograms: N/A Is the patient's height (from any visit) documented in the 22 [1] Yes, in inches | [2] Yes, in centimeters | [3] No medical record? 23 Height in inches: N/A 24 Height in centimeters: N/A Page 2. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses [1] Underweight (estimated BMI < 18.5) | [2] Normal (estimated BMI If both weight and height are not available, what is the 18.5 - 24.9) | [3] Overweight (estimated BMI 25 - 29.9) | [4] Obese 25 patient's body habitus? (estimated BMI 30 - 39.9) | [5] Extremely obese (estimated BMI > 40) | [6] Not documented Was the patient's weight documented at each of the last 26 [1] Yes | [2] No | [3] Patient has had less than three office visits three office visits? [1] Yes, it's the patient visit date above | [2] Yes, it's a date prior to the Is the date of the most recent blood pressure measurement 27 patient visit date | [3] No, the date is not documented, but results are documented in the medical record? available | [4] No, neither the date nor results are documented 28 Date of BP measurement: N/A 29 Systolic reading (mm Hg): N/A 30 Diastolic reading (mm Hg): N/A Was the patient's blood pressure measured and recorded at 31 [1] Yes | [2] No | [3] Patient has had less than three office visits each of the last three office visits? [1] Yes, recheck blood pressure at specified future date | [2] Yes, Is there a documented plan of care for this patient for blood inititate or alter pharmacologic therapy | [3] Yes, inititate or alter non- 32 pressure management that includes any of the following? pharmacologic therapy | [4] Yes, review and document patient's home (Check all that apply.) blood pressure log | [5] No blood pressure plan of care documented Is there a current diagnosis of CKD documented in the 33 [1] Yes | [2] No medical record? [1] Stage 4 (GFR 15 - 29) | [2] Stage 5 (GFR < 15 or dialysis) | [3] Not 34 What is the current stage of CKD? documented 35 Comorbid Conditions N/A [1] Clinical coronary heart disease, cerebrovascular disease, or Has the patient been diagnosed with any of the following? peripheral artery disease | [2] Heart failure | [3] History of a coronary 36 (Check all that apply.) event | [4] Diabetes mellitus | [5] Depression | [6] Autoimmune disorders | [7] Chronic pain, arthritis, or gout | [8] None of the above 37 Complications Related to Decreased Kidney Function N/A Page 3. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses Has the patient had any of the following complications [1] Hypertension | [2] Anemia | [3] Malnutrition | [4] Mineral and bone 38 secondary to decreased kidney function? (Check all that disorder (e.g., secondary hyperparathyroidism | [5] Metabolic acidosis | apply.) [6] Hyperkalemia | [7] Volume overload | [8] None of the above 39 Additional Risk Factors for Future CHD Events N/A 40 Is the patient a current smoker? [1] Yes | [2] No | [3] Not documented [1] Elevated LDL cholesterol (> 100 mg/dL) or on lipid-lowering medication | [2] Low HDL cholesterol (< 40 mg/dL for men, < 50 mg/dL Does the patient have any of the following risk factors for 41 for women) | [3] Physical inactivity (does not engage in a minimum of 30 future CHD events? (Check all that apply.) minutes of moderate-intensity activity per day for at least four days per week) | [4] None of the above Has aspirin or other antiplatelet or anticoagulant therapy 42 [1] Yes | [2] No | [3] Patient has medical contraindications to this therapy been prescribed for this patient? 43 Risk Factors for CKD Progression N/A Does the patient have a current or past history of chronic 44 [1] Yes | [2] No NSAID use? Has there been an episode of acute renal failure (ARF)/acute 45 [1] Yes | [2] No kidney injury (AKI) occurring in the last 12 months? Has the patient had studies using contrast in the last 12 46 [1] Yes | [2] No months? 47 Smoking-Cessation Support N/A 48 Is there documentation of smoking-cessation counseling? [1] Yes | [2] No Date of the most recently documented smoking-cessation 49 N/A counseling: [1] Brief advice to stop smoking | [2] Support within the office practice | During the past 12 months, what type of smoking-cessation [3] Referral to a smoking-cessation program | [4] Medication (e.g., 50 support has been offered? (Check all that apply.) nicotine replacement therapy, bupropion, varenicline) | [5] No support has been offered during the past 12 months | [6] Other Page 4. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses 51 Laboratory Tests N/A Is the date and result of the most recent eGFR assessment 52 [1] Yes | [2] No documented in the medical record? 53 Date of the most recent test: N/A 54 eGFR result (mL/min/1.73m2): N/A Is the date and result of the most recent 55 albuminuria/proteinuria assessment documented in the [1] Yes | [2] No medical record? Which of the following tests was done? (Check the most [1] Urine albumin-to-creatinine ratio (UACR) | [2] Urine protein-to- 56 recent test) creatinine (UPC) ratio 57 Date of the most recent test: N/A 58 UACR (mg/g): N/A 59 UPC ratio (mg/g): N/A Is the date and result of the most recent hemoglobin 60 [1] Yes | [2] No measurement documented in the medical record? 61 Date of the most recent test: N/A 62 Result (g/dL): N/A 63 Has the hemoglobin been < 10 g/dL in the last 12 months? [1] Yes | [2] No Is the date and result of the most recent serum ferritin 64 [1] Yes | [2] No measurement documented in the medical record? 65 Date of the most recent test: N/A 66 Result (ng/mL): N/A Is the date and result of the most recent transferrin 67 [1] Yes | [2] No saturation measurement documented in the medical record? 68 Date of the most recent test: N/A Page 5. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses 69 Result (%): N/A Is the date and result of the most recent serum calcium 70 [1] Yes | [2] No measurement documented in the medical record? Which of the following tests was done? (Check the test done 71 [1] Corrected serum calcium | [2] Uncorrected serum calcium most recently) 72 Date of the most recent test: N/A 73 Results (mg/dL): N/A Is the date and result of the most recent serum phosphorus 74 [1] Yes | [2] No measurement documented in the medical record? 75 Date of the most recent test: N/A 76 Result (mEg/L): N/A Is the date and result of the most recent serum bicarbonate 77 [1] Yes | [2] No measurement documented in the medical record? 78 Date of the most recent test: N/A 79 Result (mEg/L): N/A Is the date and result of the most recent serum potassium 80 [1] Yes | [2] No measurement documented in the medical record? 81 Date of the most recent test: N/A 82 Result (mEg/L): N/A Is the date and result of the most recent serum intact 83 parathyroid hormone measurement documented in the [1] Yes | [2] No medical record? 84 Date of the most recent test: N/A 85 Result (pg/mL): N/A Page 6. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses Is the date and result of the most recent serum 25- 86 hydroxyvitamin D (calcidiol) measurement documented in [1] Yes | [2] No the medical record? 87 Date of the most recent test: N/A 88 Result (ng/mL): N/A Is the date and result of the most recent hemoglobin A1C 89 [1] Yes | [2] No measurement documented in the medical record? 90 Date of the most recent test: N/A 91 Result (%): N/A 92 Lipid Profile N/A [1] Yes, as part of a lipid panel | [2] Yes, as an individual test or tests 93 Were fasting lipid results obtained for this patient? (cholesterol, triglycerides, HDL and/or LDL) | [3] No, lipid results were not obtained or not documented 94 Date of the most recent lipid panel: N/A 95 Was total cholesterol obtained? [1] Yes | [2] No 96 Total cholesterol date: N/A 97 Total cholesterol (mg/dL): N/A 98 Was LDL cholesterol level obtained? [1] Yes | [2] No 99 LDL date: N/A 100 LDL cholesterol (mg/dL): N/A 101 Was HDL cholesterol level obtained? [1] Yes | [2] No 102 HDL date: N/A 103 HDL cholesterol (mg/dL): N/A 104 Were triglycerides obtained? [1] Yes | [2] No Page 7. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses 105 Triglycerides date: N/A 106 Triglycerides (mg/dL): N/A 107 Management & Treatment N/A Is there documentation that the patient's current medications 108 [1] Yes | [2] No were reviewed at the most recent visit? 109 Has this patient been advised to avoid excess alcohol? [1] Yes | [2] No Is the patient receiving therapy with an Erythropoiesis- 110 [1] Yes | [2] No stimulating agent (ESA)? 111 What was the patient's hemoglobin when ESA last given? N/A Is there a documented plan of care to decrease the patient's 112 [1] Yes | [2] No hemoglobin? [1] ACE inhibitor and/or ARB | [2] HMG-CoA reductase inhibitor (statin) Which of the following medications been prescribed for this or other lipid-lowering therapy | [3] Metformin | [4] Iron supplement | [5] 113 patient? (Check all that apply.) Phosphate binder | [6] Alkalinization therapy (e.g., sodium bicarbonate) | [7] Vitamin D supplement | [8] None of the above What dietary interventions have been done? (Check all that [1] Referal to dietitian | [2] Individual nutrition plan prescribed | [3] 114 apply.) Sodium restricted diet prescribed | [4] Other | [5] None of the above 115 Has the dietitian's summary report been received? [1] Yes | [2] No 116 Immunizations N/A [1] Yes | [2] No, patient refused | [3] No, not given for medical reason Has the patient received an influenza vaccine during the 117 (e.g., allergy, documented immunity) | [4] No, vaccine should have been most recent flu season? given | [5] Not documented [1] Yes | [2] No, patient refused | [3] No, not given for medical reason 118 Has the patient received pneumococcal vaccine? (e.g., allergy, documented immunity) | [4] No, vaccine should have been given | [5] Not documented Page 8. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses [1] Yes | [2] No, patient refused | [3] No, not given for medical reason Has the patient received the completed hepatitis B 119 (e.g., allergy, documented immunity) | [4] No, vaccine should have been vaccination series? given | [5] Not documented 120 Coordination of Care N/A 121 Has the patient been referred to a nephrologist? [1] Yes | [2] No | [3] Not applicable; I am a nephrologist Was nephrologist's summary report received from the 122 [1] Yes | [2] No nephrologist? Was the nephrologist's summary report sent to the referring 123 [1] Yes | [2] No physician? Has the patient been referred to a vascular-access specialist [1] Yes | [2] No | [3] Not applicable; patient prefers peritoneal dialysis | 124 or surgeon? [4] No, dialysis is not a practical option for this patient Has the vascular-access specialist or surgeon's summary 125 [1] Yes | [2] No report been received? [1] Yes | [2] No | [3] No, transplant is not a practical option for this 126 Has the patient been referred for transplant evaluation? patient | [4] Patient does not want to have transplantation 127 Does the chart document the following patient preferences? N/A 128 Preferences for life-sustaining care [1] Yes | [2] No 129 Designated surrogate decision maker [1] Yes | [2] No 130 Functional Status N/A [1] Fully active; able to carry on all performance without restriction. | [2] Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (e.g., light house work, Which of the following best describes this patient's current office work). | [3] Ambulatory and capable of self-care but unable to 131 physical functional status (e.g., physical ability)? carry out any work activities. Up and about more than 50% of waking hours. | [4] Capable of only limited self-care; confined to bed or chair more than 50% of waking hours. | [5] Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair. Page 9. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
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  Chronic Kidney DiseasePIM Chart Questions No. Question Text Responses Is the patient independent in instrumental activities of daily 132 [1] Yes | [2] No | [3] Not documented living (IADLs)? 133 Is the patient independent in activities of daily living (ADLs)? [1] Yes | [2] No | [3] Not documented 134 Barriers to Self Care N/A Is there evidence in this patient's medical record suggesting 135 that one or more of the following factors limits the patient's N/A ability to engage in self-care? 136 Psychiatric illness or cognitive impairment [1] Yes | [2] No 137 Problems with adherence [1] Yes | [2] No 138 Other medical conditions [1] Yes | [2] No 139 Social factors [1] Yes | [2] No Page 10. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011