Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
This paper abstraction tool is provided as an optional, informal mechanism to aid
psychiatric facilities and hospital psychiatric units in the collection of the measures
for the CMS Inpatient Psychiatric Facility Quality Reporting Program. The tool is
designed to collect patient specific data; 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 paper abstraction tool. If there are any
questions or concerns regarding use of this paper abstraction tool, please contact
the IPFQR Program Support Contractor at IPFQualityReporting@hcqis.org.
Birthdate: ________/________/_________________
UTD is not an allowable entry.
Patient Identifier: _________________________________
Admission Date: ________/________/_________________
UTD is not an allowable entry.
Discharge Date: ________/________/_________________
UTD is not an allowable entry.
Individual Medical Record Data Collection Tool
Select the applicable Strata based on the Patient Age at Discharge (in years)
(Discharge Date – Birth Date) for this record:
_____
Age 1 year through 12 years
(Patient Age at Discharge ≥1 year and < 13 years)
_____
Age 13 years through 17 years
(Patient Age at Discharge ≥ 13 years and < 18 years)
_____
Age 18 years through 64 years
(Patient Age at Discharge ≥ 18 years and < 65 years)
_____
Age greater than or equal to 65 years
(Patient Age at Discharge ≥ 65 years)
During review of the record, the abstractor will be prompted to enter a 0 or a 1 for both
the numerator and denominator for the measures below.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 1 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
Patient Level
HBIPS-4
_________ Numerator
_________ Denominator
HBIPS-5
_________ Numerator
_________ Denominator
HBIPS-6
_________ Numerator
_________ Denominator
HBIPS-7
_________ Numerator
_________ Denominator
The information from each medical record will be used to determine the numerator and
denominator, which will be aggregated for submission to QualityNet.
HBIPS-4
1. What was the patient’s discharge disposition? (Discharge Disposition)
_____ 1
Home
_____ 2
Hospice – Home
_____ 3
Hospice – Health Care Facility
_____ 4
Acute Care Facility
_____ 5
Other Health Care Facility
_____ 6
Expired
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 2 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
_____ 7 Left Against Medical Advice (AMA)
_____ 8 Not Documented or Unable to Determine (UTD)
a. If Discharge Disposition equals 6, then the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case
will not be included in the numerator or denominator for HBIPS-4. Add
0 to the numerator and denominator for HBIPS-4.
b. If Discharge Disposition equals 1, 2, 3, 4, 5, 7, or 8, then continue and
proceed to Psychiatric Care Setting for HBIPS-4.
2. Did the patient receive care in an inpatient psychiatric setting? (Psychiatric
Care Setting)
_____ (Yes) The patient received care in an inpatient psychiatric setting.
_____ (No) The patient did not receive care in an inpatient psychiatric setting.
a. If Psychiatric Care Setting equals Yes, then continue and proceed to
Patient Referral to Next Level of Care Provider.
b. If Psychiatric Care Setting equals No, then the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case
will not be included in the numerator or denominator for HBIPS-4. Add
0 to the numerator and denominator for HBIPS-4.
3. Is there documentation in the medical record that the patient was referred to
the next level of care provider upon discharge from a hospital-based inpatient
psychiatric setting? (Patient Referral to Next Level of Care Provider)
_____ 1 The medical record contains documentation that the patient was referred
to the next level of care provider upon discharge from a hospital-based
inpatient psychiatric setting.
_____ 2 The medical record contains documentation that the patient or guardian
refused the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting OR refused to authorize release of
information OR readmission within 5 days of discharge.
_____ 3 The medical record contains documentation that the patient eloped OR
failed to return from leave and was discharged OR that the patient has not
yet been discharged from the hospital OR discharged from the hospital to
another level of care outside of the hospital system from a setting other
than a Psychiatric Care Setting. Residence outside U.S. after discharge.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 3 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
_____ 4 The medical record contains documentation that the patient was not
referred to the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting for a reason other than above.
_____ 5 The medical record does not contain documentation that the patient was
referred to the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting OR unable to determine from medical
record documentation.
a. If Patient Referral to Next Level of Care Provider equals 3, then the
case will be excluded (Measure Category Assignment of “B”). Stop
abstracting. The case will not be included in the numerator or
denominator for HBIPS-4. Add 0 to the numerator and denominator for
HBIPS-4.
b. If Patient Referral to Next Level of Care Provider equals 1, 2, 4, or 5,
then continue and proceed to Number of Antipsychotic Medications
Prescribed at Discharge.
4. What is the documented number of antipsychotic medications prescribed for
the patient at discharge? (Number of Antipsychotic Medications Prescribed at
Discharge)
_____ (0-99)
_____ UTD
a. If Number of Antipsychotic Medications Prescribed at Discharge equals
0, the case will be excluded (Measure Category Assignment of “B”).
Stop abstracting. The case will not be included in the numerator or
denominator for HBIPS-4. Add 0 to the numerator and denominator for
HBIPS-4.
b. If Number of Antipsychotic Medications Prescribed at Discharge equals
1, then the case will be included (Measure Category Assignment of
“D”). Stop abstracting. Add 1 to the denominator for HBIPS-4. Add 0
to the numerator for HBIPS-4.
c. If Number of Antipsychotic Medications Prescribed at Discharge is
greater than or equal to 2 or equals UTD, the case will be included
(Measure Category Assignment of “E”). Stop abstracting. Add 1 to
BOTH the numerator and denominator for HBIPS-4.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 4 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
HBIPS-5
1. What is the Length of Stay? Length of Stay (in days) equals Discharge Date
minus Admission Date.
a. If Length of Stay is less than or equal to 3 days, then the case will be
excluded (Measure Category Assignment of “B”). Stop abstracting.
The case will not be included in the numerator or denominator for
HBIPS-5. Add 0 to the numerator and denominator for HBIPS-5.
b. If Length of Stay is greater than 3 days, then continue and proceed to
Discharge Disposition.
2. What was the patient’s discharge disposition? (Discharge Disposition)
_____ 1 Home
_____ 2 Hospice – Home
_____ 3 Hospice – Health Care Facility
_____ 4 Acute Care Facility
_____ 5 Other Health Care Facility
_____ 6 Expired
_____ 7 Left Against Medical Advice (AMA)
_____ 8 Not Documented or Unable to Determine (UTD)
a. If Discharge Disposition equals 6, then the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case
will not be included in the numerator or denominator for HBIPS-5. Add
0 to the numerator and denominator for HBIPS-5.
b. If Discharge Disposition equals 1, 2, 3, 4, 5, 7, or 8, then continue and
proceed to Psychiatric Care Setting for HBIPS-5.
3. Did the patient receive care in an inpatient psychiatric setting? (Psychiatric
Care Setting)
_____ (Yes) The patient received care in an inpatient psychiatric setting.
_____ (No) The patient did not receive care in an inpatient psychiatric setting.
a. If Psychiatric Care Setting equals Yes, then continue and proceed to
Patient Referral to Next Level of Care Provider.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 5 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
b. If Psychiatric Care Setting equals No, then the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case
will not be included in the numerator or denominator for HBIPS-5. Add
0 to the numerator and denominator for HBIPS-5.
4. Is there documentation in the medical record that the patient was referred to
the next level of care provider upon discharge from a hospital-based inpatient
psychiatric setting? (Patient Referral to Next Level of Care Provider)
_____ 1 The medical record contains documentation that the patient was referred
to the next level of care provider upon discharge from a hospital-based
inpatient psychiatric setting.
_____ 2 The medical record contains documentation that the patient or guardian
refused the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting OR refused to authorize release of
information OR readmission within 5 days after discharge.
_____ 3 The medical record contains documentation that the patient eloped OR
failed to return from leave and was discharged OR that the patient has not
yet been discharged from the hospital OR discharged from the hospital to
another level of care outside of the hospital system from a setting other
than a Psychiatric Care Setting. Residence outside U.S. after discharge.
_____ 4 The medical record contains documentation that the patient was not
referred to the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting for a reason other than above.
_____ 5 The medical record does not contain documentation that the patient was
referred to the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting OR unable to determine from medical
record documentation.
a. If Patient Referral to Next Level of Care Provider equals 3, then the
case will be excluded (Measure Category Assignment of “B”). Stop
abstracting. The case will not be included in the numerator or
denominator for HBIPS-5. Add 0 to the numerator and denominator for
HBIPS-5.
b. If Patient Referral to Next Level of Care Provider equals 1, 2, 4, or 5,
then continue and proceed to Number of Antipsychotic Medications
Prescribed at Discharge.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 6 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
5. What is the documented number of antipsychotic medications prescribed for
the patient at discharge? (Number of Antipsychotic Medications Prescribed at
Discharge)
_____ (0-99)
_____ UTD
a. If Number of Antipsychotic Medications Prescribed at Discharge is less
than or equal to 1, then the case will be excluded (Measure Category
Assignment of “B”). Stop abstracting. The case will not be included in
the numerator or denominator for HBIPS-5. Add 0 to the numerator
and denominator for HBIPS-5.
b. If Number of Antipsychotic Medications Prescribed at Discharge equals
UTD, then the case will be included (Measure Category Assignment of
“D”). Stop abstracting. Add 1 to the denominator for HBIPS-5. Add 0
to the numerator for HBIPS-5.
c. If Number of Antipsychotic Medications Prescribed at Discharge is
greater than or equal to 2, then continue and proceed to Appropriate
Justification for Multiple Antipsychotic Medications.
6. Is there documentation in the medical record of appropriate justification for
the patient being discharged on 2 or more antipsychotic medications?
(Appropriate Justification for Multiple Antipsychotic Medications)
_____ 1 The medical record contains documentation of a history of a minimum of 3
failed multiple trials of monotherapy.
_____ 2 The medical record contains documentation of a recommended plan to
taper to monotherapy due to previous use of multiple antipsychotic
medications OR documentation of a cross-taper in progress at the time of
discharge.
_____ 3 The medical record contains documentation of augmentation of Clozapine.
_____ 4 The medical record contains documentation of a justification other than
those listed in Allowable Values 1-3.
_____ 5 The medical record does not contain documentation supporting the reason
for being discharged on 2 or more antipsychotic medications OR unable to
determine from medical record documentation.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 7 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
a. If Appropriate Justification for Multiple Antipsychotic Medications
equals 1, 2, or 3, then the case will be included (Measure Category
Assignment of “E”). Stop abstracting. Add 1 to BOTH the numerator
and denominator for HBIPS-5.
b. If Appropriate Justification for Multiple Antipsychotic Medications
equals 4 or 5, then the case will be included (Measure Category
Assignment of “D”). Stop abstracting. Add 1 to the denominator for
HBIPS-5. Add 0 to the numerator for HBIPS-5.
HBIPS-6
7. What was the patient’s discharge disposition? (Discharge Disposition)
_____ 1 Home
_____ 2 Hospice – Home
_____ 3 Hospice – Health Care Facility
_____ 4 Acute Care Facility
_____ 5 Other Health Care Facility
_____ 6 Expired
_____ 7 Left Against Medical Advice (AMA)
_____ 8 Not Documented or Unable to Determine (UTD)
a. If Discharge Disposition equals 6, then the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case
will not be included in the numerator or denominator for HBIPS-6. Add
0 to the numerator and denominator for HBIPS-6.
b. If Discharge Disposition equals 1, 2, 3, 4, 5, 7, or 8, then continue and
proceed to Psychiatric Care Setting for HBIPS-6.
8. Did the patient receive care in an inpatient psychiatric setting? (Psychiatric
Care Setting)
_____ (Yes) The patient received care in an inpatient psychiatric setting.
_____ (No) The patient did not receive care in an inpatient psychiatric setting.
a. If Psychiatric Care Setting equals Yes, then continue and proceed to
Patient Referral to Next Level of Care Provider.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 8 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
b. If Psychiatric Care Setting equals No, then the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case
will not be included in the numerator or denominator for HBIPS-6. Add
0 to the numerator and denominator for HBIPS-6.
9. Is there documentation in the medical record that the patient was referred to
the next level of care provider upon discharge from a hospital-based inpatient
psychiatric setting? (Patient Referral to Next Level of Care Provider)
_____ 1 The medical record contains documentation that the patient was referred
to the next level of care provider upon discharge from a hospital-based
inpatient psychiatric setting.
_____ 2 The medical record contains documentation that the patient or guardian
refused the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting OR refused to authorize release of
information OR readmission within 5 days after discharge.
_____ 3 The medical record contains documentation that the patient eloped OR
failed to return from leave and was discharged OR that the patient has not
yet been discharged from the hospital OR discharged from the hospital to
another level of care outside of the hospital system from a setting other
than a Psychiatric Care Setting. Residence outside U.S. after discharge.
_____ 4 The medical record contains documentation that the patient was not
referred to the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting for a reason other than above.
_____ 5 The medical record does not contain documentation that the patient was
referred to the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting OR unable to determine from medical
record documentation.
a. If Patient Referral to Next Level of Care Provider equals 1, 4, or 5, then
continue and proceed to Continuing Care Plan-Principal Discharge
Diagnosis.
b. If Patient Referral to Next Level of Care Provider equals 2 or 3, then
the case will be excluded (Measure Category Assignment of “B”). Stop
abstracting. The case will not be included in the numerator or
denominator for HBIPS-6. Add 0 to the numerator and denominator for
HBIPS-6.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 9 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
10. Is there documentation in the medical record of a continuing care plan which
includes the principal discharge diagnosis AND was the continuing care plan,
including the principal discharge diagnosis, transmitted to the next level of
care provider no later than the fifth post-discharge day? (Continuing Care
Plan-Principal Discharge Diagnosis)
_____ 1 The medical record contains a continuing care plan which includes the
principal discharge diagnosis AND was transmitted to the next level of
care provider no later than the fifth post-discharge day.
_____ 2 The medical record contains a continuing care plan which includes the
principal discharge diagnosis but was not transmitted to the next level of
care provider by the fifth post-discharge day.
_____ 3 The medical record does not contain a continuing care plan which
includes the principal discharge diagnosis OR unable to determine from
medical record documentation.
a. If Continuing Care Plan-Principal Discharge Diagnosis equals 3, then
the case is included (Measure Category Assignment of “D”). Stop
abstracting. Add 1 to the denominator for HBIPS-6. Add 0 to the
numerator for HBIPS-6. (Note: The case will be included in the
denominator at this point; however, for quality and internal review
purposes, it is recommended that you abstract and evaluate all of the
Continuing Care Plan elements.)
b. If Continuing Care Plan-Principal Discharge Diagnosis equals 1 or 2,
then continue and proceed to Continuing Care Plan-Reason for
Hospitalization.
11. Is there documentation in the medical record of a continuing care plan which
includes the reason for hospitalization AND was the continuing care plan,
including the reason for hospitalization, transmitted to the next level of care
provider no later than the fifth post-discharge day? (Continuing Care PlanReason for Hospitalization)
_____ 1 The medical record contains a continuing care plan which includes the
reason for hospitalization AND was transmitted to the next level of care
provider no later than the fifth post-discharge day.
_____ 2 The medical record contains a continuing care plan which includes the
reason for hospitalization but was not transmitted to the next level of care
provider by the fifth post-discharge day.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 10 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
_____ 3
The medical record does not contain a continuing care plan which
includes the reason for hospitalization OR unable to determine from
medical record documentation.
a. If Continuing Care Plan-Reason for Hospitalization equals 3, then the
case is included (Measure Category Assignment of “D”). Stop
abstracting. Add 1 to the denominator for HBIPS-6. Add 0 to the
numerator for HBIPS-6. (Note: The case will be included in the
denominator at this point; however, for quality and internal review
purposes, it is recommended that you abstract and evaluate all of the
Continuing Care Plan elements.)
b. If Continuing Care Plan-Reason for Hospitalization equals 1 or 2, then
continue and proceed to Continuing Care Plan-Discharge Medications.
12. Is there documentation in the medical record of a continuing care plan which
includes the discharge medications, dosage, and indication for use or states
no medications were ordered at discharge AND was the continuing care plan,
including discharge medications, transmitted to the next level of care provider
no later than the fifth post-discharge day? (Continuing Care Plan-Discharge
Medications)
_____ 1 The medical record contains a continuing care plan which includes the
discharge medications, dosage, and indication for use or that no
medications were ordered at discharge and was transmitted to the next
level of care provider no later than the fifth post-discharge day.
_____ 2 The medical record contains a continuing care plan which includes the
discharge medications, dosage, and indication for use or that no
medications were ordered at discharge but was not transmitted to the next
level of care provider by the fifth post-discharge day.
_____ 3 The medical record does not contain a continuing care plan which
includes the discharge medications, dosage, and indication for use or that
no medications were ordered at discharge OR unable to determine from
medical record documentation OR if more than one list exists in the
continuing care plan and do not match.
a. If Continuing Care Plan-Discharge Medications equals 3, then the case
is included (Measure Category Assignment of “D”). Stop abstracting.
Add 1 to the denominator for HBIPS-6. Add 0 to the numerator for
HBIPS-6. (Note: The case will be included in the denominator at this
point; however, for quality and internal review purposes, it is
recommended that you abstract and evaluate all of the Continuing
Care Plan elements.)
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 11 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
b. If Continuing Care Plan-Discharge Medications equals 1 or 2, then
continue and proceed to Continuing Care Plan-Next Level of Care.
13. Is there documentation in the medical record of a continuing care plan which
includes next level of care recommendations AND was the continuing care
plan, including next level of care recommendations, transmitted to the next
level of care provider no later than the fifth post-discharge day? (Continuing
Care Plan-Next Level of Care)
_____ 1 The medical record contains a continuing care plan which includes next
level of care recommendations AND was transmitted to the next level of
care provider no later than the fifth post-discharge day.
_____ 2 The medical record contains a continuing care plan which includes next
level of care recommendations, but it was not transmitted to the next level
of care provider by the fifth post-discharge day.
_____ 3 The medical record does not contain a continuing care plan which
includes next level of care recommendations OR unable to determine from
medical record documentation.
a. If Continuing Care Plan-Next Level of Care equals 3, then the case is
included (Measure Category Assignment of “D”). Stop abstracting.
Add 1 to the denominator for HBIPS-6. Add 0 to the numerator for
HBIPS-6.
b. If Continuing Care Plan-Next Level of Care equals 1 or 2, then the
case is included (Measure Category Assignment of “E”). Stop
abstracting. Add 1 to BOTH the numerator and denominator for
HBIPS-6.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 12 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
HBIPS-7
1. What was the patient’s discharge disposition? (Discharge Disposition)
_____ 1 Home
_____ 2 Hospice – Home
_____ 3 Hospice – Health Care Facility
_____ 4 Acute Care Facility
_____ 5 Other Health Care Facility
_____ 6 Expired
_____ 7 Left Against Medical Advice (AMA)
_____ 8 Not Documented or Unable to Determine (UTD)
a. If Discharge Disposition equals 6, then the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case
will not be included in the numerator or denominator for HBIPS-7. Add
0 to the numerator and denominator for HBIPS-7.
b. If Discharge Disposition equals 1, 2, 3, 4, 5, 7, or 8, then continue and
proceed to Psychiatric Care Setting for HBIPS-7.
2. Did the patient receive care in an inpatient psychiatric setting? (Psychiatric
Care Setting)
_____ (Yes) The patient received care in an inpatient psychiatric setting.
_____ (No) The patient did not receive care in an inpatient psychiatric setting.
a. If Psychiatric Care Setting equals Yes, then continue and proceed to
Patient Referral to Next Level of Care Provider.
b. If Psychiatric Care Setting equals No, then the case will be excluded
(Measure Category Assignment of “B”). Stop abstracting. The case
will not be included in the numerator or denominator for HBIPS-7. Add
0 to the numerator and denominator for HBIPS-7.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 13 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
3. Is there documentation in the medical record that the patient was referred to
the next level of care provider upon discharge from a hospital-based inpatient
psychiatric setting? (Patient Referral to Next Level of Care Provider)
_____ 1 The medical record contains documentation that the patient was referred
to the next level of care provider upon discharge from a hospital-based
inpatient psychiatric setting.
_____ 2 The medical record contains documentation that the patient or guardian
refused the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting OR refused to authorize release of
information OR readmission within 5 days of discharge.
_____ 3 The medical record contains documentation that the patient eloped OR
failed to return from leave and was discharged OR that the patient has not
yet been discharged from the hospital OR discharged from the hospital to
another level of care outside of the hospital system from a setting other
than a Psychiatric Care Setting. Residence outside the U.S. after
discharge.
_____ 4 The medical record contains documentation that the patient was not
referred to the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting for a reason other than above.
_____ 5 The medical record does not contain documentation that the patient was
referred to the next level of care provider upon discharge from a hospitalbased inpatient psychiatric setting OR unable to determine from medical
record documentation.
a. If Patient Referral to Next Level of Care Provider equals 1, 4, or 5, then
continue and proceed to Continuing Care Plan-Principal Discharge
Diagnosis.
b. If Patient Referral to Next Level of Care Provider equals 2 or 3, then
the case will be excluded (Measure Category Assignment of “B”). Stop
abstracting. The case will not be included in the numerator or
denominator for HBIPS-7. Add 0 to the numerator and denominator for
HBIPS-7.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 14 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
4. Is there documentation in the medical record of a continuing care plan which
includes the principal discharge diagnosis AND was the continuing care plan,
including the principal discharge diagnosis, transmitted to the next level of
care provider no later than the fifth post-discharge day? (Continuing Care
Plan-Principal Discharge Diagnosis)
_____ 1 The medical record contains a continuing care plan which includes the
principal discharge diagnosis AND was transmitted to the next level of
care provider no later than the fifth post-discharge day.
_____ 2 The medical record contains a continuing care plan which includes the
principal discharge diagnosis but was not transmitted to the next level of
care provider by the fifth post-discharge day.
_____ 3 The medical record does not contain a continuing care plan which
includes the principal discharge diagnosis OR unable to determine from
medical record documentation.
a. If Continuing Care Plan-Principal Discharge Diagnosis equals 2 or 3,
then the case is included (Measure Category Assignment of “D”). Stop
abstracting. Add 1 to the denominator for HBIPS-7. Add 0 to the
numerator for HBIPS-7.
b. If Continuing Care Plan-Principal Discharge Diagnosis equals 1, then
continue and proceed to Continuing Care Plan-Reason for
Hospitalization.
5. Is there documentation in the medical record of a continuing care plan which
includes the reason for hospitalization AND was the continuing care plan,
including the reason for hospitalization, transmitted to the next level of care
provider no later than the fifth post-discharge day? (Continuing Care PlanReason for Hospitalization)
_____ 1 The medical record contains a continuing care plan which includes the
reason for hospitalization AND was transmitted to the next level of care
provider no later than the fifth post-discharge day.
_____ 2 The medical record contains a continuing care plan which includes the
reason for hospitalization but was not transmitted to the next level of care
provider by the fifth post-discharge day.
_____ 3 The medical record does not contain a continuing care plan which
includes the reason for hospitalization OR unable to determine from
medical record documentation.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 15 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
a. If Continuing Care Plan-Reason for Hospitalization equals 2 or 3, then
the case is included (Measure Category Assignment of “D”). Stop
abstracting. Add 1 to the denominator for HBIPS-7. Add 0 to the
numerator for HBIPS-7.
b. If Continuing Care Plan-Reason for Hospitalization equals 1, then
continue and proceed to Continuing Care Plan-Discharge Medications.
6. Is there documentation in the medical record of a continuing care plan which
includes the discharge medications, dosage, and indication for use or states
no medications were prescribed at discharge AND was the continuing care
plan, including discharge medications, transmitted to the next level of care
provider no later than the fifth post-discharge day? (Continuing Care PlanDischarge Medications)
_____ 1 The medical record contains a continuing care plan which includes the
discharge medications, dosage, and indication for use or that no
medications were ordered at discharge AND was transmitted to the next
level of care provider no later than the fifth post-discharge day.
_____ 2 The medical record contains a continuing care plan which includes the
discharge medications, dosage, and indication for use or that no
medications were ordered at discharge but was not transmitted to the next
level of care provider by the fifth post-discharge day.
_____ 3 The medical record does not contain a continuing care plan which
includes the discharge medications, dosage, and indication for use or that
no medications were ordered at discharge OR unable to determine from
medical record documentation OR if more than one list exists in the
continuing care plan and do not match.
a. If Continuing Care Plan-Discharge Medications equals 2 or 3, then the
case is included (Measure Category Assignment of “D”). Stop
abstracting. Add 1 to the denominator for HBIPS-7. Add 0 to the
numerator for HBIPS-7.
b. If Continuing Care Plan-Discharge Medications equals 1, then continue
and proceed to Continuing Care Plan-Next Level of Care.
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 16 of 17
Hospital-Based Inpatient Psychiatric Services
Paper Tool for Discharge Measures HBIPS-4 through -7
01-01-2015 (Q1 2015) through 9-30-2015 (Q3 2015)
7. Is there documentation in the medical record of a continuing care plan which
includes next level of care recommendations AND was the continuing care
plan, including next level of care recommendations, transmitted to the next
level of care provider no later than the fifth post-discharge day? (Continuing
Care Plan-Next Level of Care)
_____ 1 The medical record contains a continuing care plan which includes next
level of care recommendations AND was transmitted to the next level of
care provider no later than the fifth post-discharge day.
_____ 2 The medical record contains a continuing care plan which includes next
level of care recommendations but was not transmitted to the next level of
care provider by the fifth post-discharge day.
_____ 3 The medical record does not contain a continuing care plan which
includes next level of care recommendations OR unable to determine from
medical record documentation.
a. If Continuing Care Plan-Next Level of Care equals 2 or 3, then the
case is included (Measure Category Assignment of “D”). Stop
abstracting. Add 1 to the denominator for HBIPS-7. Add 0 to the
numerator for HBIPS-7.
b. If Continuing Care Plan-Next Level of Care equals 1, then the case is
included (Measure Category Assignment of “E”). Stop abstracting.
Add 1 to BOTH the numerator and denominator for HBIPS-7.
This material was prepared by the Inpatient Value, Incentives, and Quality Reporting Outreach and Education
Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. HHSM-500-2013-13007I, FL-IQR-Ch8-02052015-02
CMS Abstraction Paper Tool – HBIPS-4 through -7
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
Page 17 of 17