Peritoneal Dialysis Clinical Performance Measures Data Collection Form 2005 {CMS-821}

PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 [Before completing please read instructions at the bottom of this page a nd on pages 5 and 6] PATIENT IDENTIFICATION MAKE C ORRECTIONS TO PATIENT INFORMATION ON LABEL IN THE SPACE BELOW Place Patient Data Label Here 12. If this patient is unknown or was not dialyzed in the facility at any time during OCT 2004-MAR 2 005 return the blank form to the Network. 13. Patients Ethnicity (Check appropriate box). o non-Hispanic o Hispanic, Mexican American (Chicano) o Hispanic, Puerto Rican o Hispanic, Cuban American o Hispanic, Other o Unknown . 14a.Patients height (MUST COMPLETE): _________inches OR _________centimeters ( only for patients < 18 years old, provide date when height was measured: ____ / ___ / _____ ) (mm) (dd) (yyyy) 14b.Patients weight (abdomen empty) (first clinic visit weight after Oct. 1, 2004): _______ . ___lbs. OR ______ . ___ kg. 15. Did patient have limb amputation(s) prior to Mar. 31, 2005: o Yes o No o Unknown 16. Has the patient ever been diagnosed with any type of diabetes? o Yes (go to 17) o No (go to 18) o Unknown (go to 18) 17.If question 16 was answered YES, was the patient taking medications to control the diabetes during the study period? o Yes o No o Unknown If YES , was the patient using insulin during the study period? o Yes o No o Unknown Individual Completing Form (Please print): First name: ___________________________ Last name: ___________________ _________________ Title: _______________ Phone number: (_______) _________ - __________ Fax number: (_______) _________ - ____________ INSTRUCTIONS FOR COMPLETING THE PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 The label on the top left side of this form contains the following patient identifying information (#s 1-11). If the information is incorrect make corrections to the right of the label. 1. LAST and first name. 2. DATE of birth (DOB) as MM/DD/YYYY. 3. SOCIAL Security Number (SSN). 4. HEALTH Insurance Claim Number (HIC), (same as Medicare number). 5. GENDER (1=Male; 2=Female). 6. RACE (1=American Indian/Alaska Native; 2=Asian; 3=Black; 4=White; 7. PRIMARY cause of renal failure by 5=Unknown; 6=Pacific Islander; 7=Mid East Arabian; 8=Indian Subconti- CMS-2728 code. nent; 9=Other/Multiracial). 9. ESRD Network number. 8. DATE, as MM/DD/YYYY, that the patient began a regular course of dialysis. Do not make corrections to this item. 10. Facilitys Medicare provider number. 11. The most RECENT date this patient returned to peritoneal dialysis following: transplant failure, an episode of regained kidney function, or switched modality. 12. If the patient is unknown or if the patient was not dialyzed in the facility at any time during OCT 2004 through MAR 2005, send the blank form back to the ESRD Network office. Provide the name and address of the facility providing services to this patient on December 31, 2004, if known. 13. Patients Ethnicity. Please verify the patients ethnicity with the patient and check appropriate box. 14a.Enter the patients height in inches or centimeters. HEIGHT MUST BE ENTERED, do not leave this field blank. You may ask the patient his/her height to obtain this information. If the patient ha d both legs amputated, record pre-amputation height and check YES for item 15. 14b.Enter the patients weight (abdomen empty) in pounds or kilograms. Use the FIRST CLINIC VISIT weight on or after October 1, 2004. 15. For the purpose of this study, check NO if this patient has had toe(s), finger(s), or mid-foot (Symes) amputation; bcheckut YES if this patient has had a below-knee, below-elbow, or more proximal (extensive) amputation prior to Mar. 31, 2005. 16. Check either Yes, No, or Unknown to indicate if the patient has ever been diagnosed with any type of diabetes. If YES , proceed to question 17. 17.Check either Yes, No, or Unknown to indicate if the patient was taking medications to control the diabetes during the study period. If the answer to 17 is YES, please check either Yes, No, or Unknown to indicate if the patient was using insulin during the study period. Study period is OCT 2004 -MAR 2005. PLEASE COMPLETE ITEMS 18 THROUGH 24 ON PAGE 2, 3, AND 4 OF THIS DATA COLLECTION FORM. American LegalNet, Inc.CMS 821 (Rev.1/20/05) INSTRUCTIONS FOR COMPLETING THESE ITEMS ARE ON PAGES 5 AND 6. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 2 PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 (CONTINUED) 18. ANEMIA MANAGEMENT: For each lab question below, enter the first lab value obtained for each two-month time period: OCT-NOV 2004, DEC 2004-JAN 2005, FEB-MAR 2005. Include the date each lab was drawn. Enter NF/NP if the lab value cannot be located. OCT-NOV 2004 DEC 2004-J FEB-MAR 2005AN 2005 A. First laboratory hemoglobin (Hgb) during ____ ____ . ____ g/dL ____ ____ . ____ g/dL ____ ____ . ____ g/dL the two-month time period (If NF/NP go to 18C)Date: ____/____/____ Date: ____/____/____ Date: ____/____/____ B.1.a. Did the patient have a prescription for EpoetinEpoetin: Epoetin: Epoetin: at anytime during the 28 days before the Hgb ino Yes o No o Yes o No o Yes o No 18A was drawn? o Unknown o Unknown o Unknown B.1.b. Did the patient have a prescription for Darbepoetin: Darbepoetin: Darbepoetin: Darbepoetin (Aranesp) at anytime during theo Yes o No o Yes o No o Yes o No 28 days before the Hgb in 18A was drawn? o Unknown o Unknown o Unknown B.2.a. What was the TOTAL PRESCRIBED EpoetinEpoetin: Epoetin: Epoetin: dose in effect prior to the 28 days BEFORE __________ units/28 days __________units/28 days__________ units/28 days the Hgb in 18A was drawn? (Instructions on page 5) B.2.b.What was the TOTAL PRESCRIBED DarbepoetinDarbepoetin: Darbepoetin: Darbepoetin: dose in effect prior to the 28 days BEFORE the__________ mcg/28days __________ mcg/28days __________ mcg/28 days Hgb in 18A was drawn? (Instructions on page 5) B.3.a. How many doses per month (28 days) of Epoetin: Epoetin: Epoetin: Epoetin was prescribed? __________ per 28 days __________ per 28 days __________ per 28 days B.3.b. How many doses per month (28 days) of Darbepoetin: Darbepoetin: Darbepoetin: Darbepoetin was prescribed? __________ per 28 days __________ per 28 days __________ per 28 days B.4.a. What was the prescribed route of admini-Epoetin: Epoetin: Epoetin: stration for Epoetin? (Check all that apply)o IV o SC o Unknown o IV o SC o Unknown o IV o SC o Unknown B.4.b. What was the prescri