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Key Clinical Interventions and Documentation Summary for Preventive Care


The successful documentation and completion of clinical quality measurement requirements requires many interventions to take place within a practice. The following resource provides a summation of the key clinical interventions that can be used for preventive care quality improvement and includes the general data elements needed for measure calculation. This resource is intended for educational purposes only. Practices should work with their vendor to determine which CQMs their EHR system are certified to report on, and any specific workflow changes needed to ensure CQMs calculate properly in their specific EHR system

The following information is presented in a series of tables:

For more information on the specific data elements required for clinical quality measures, visit the Meaningful Use portal in USHIK.

For further information on CQMs and Meaningful Use, please visit: EHR Incentive Programs - Centers for Medicare & Medicaid Services

Meaningful Use Preventive Care Measures


This table lists most of the Meaningful Use Measures applicable for preventive care, with the associated National Quality Forum (NQF) and CMS numbers noted parenthetically.

Meaningful Use Preventive Care Measures
Cervical Cancer Screening (NQF# 0032; CMS124v7)
Breast Cancer Screening (NQF# 2372; CMS125v7)
Colorectal Cancer Screening (NQF# 0034; CMS130v7)
Pneumonia Vaccination for Older Adults (NQF# Not Applicable; CMS127v7)
Chlamydia Screening for Women (NQF# 0033; CMS153v7)
Childhood Immunization Status (NQF# 0038; CMS117v7)
Adult Weight Screening and Follow-up (NQF# 0421; CMS69v7)
Weight Assessment and Counseling for Children and Adolescents (NQF# 0024; CMS155v7)
Preventive Care and Screening: Influenza Immunization for Patients 50 Years Old or Older (NQF# 0041; CMS147v8)
Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment (NQF# 0028; CMS138v7)
Preventive Care and Screening Measure Pair: b) Tobacco Cessation Intervention (NQF# 0028; CMS138v7)
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (NQF# 0418; CMS2v8)
Documentation of Current Medications in the Medical Record (NQF# 0419; CMS68v8)
Preventive Care and Screening: Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# Not Applicable; CMS61v6)
Preventive Care and Screening: Risk-Stratified Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# Not Applicable; CMS64v6)
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (NQF# Not Applicable; CMS22v7)

Key Clinical Interventions


This table lists key interventions to be completed during a patient’s visit. Documentation of these interventions in the electronic health record will help ensure all of the necessary information needed to calculate Meaningful Use preventive care measures is available. For interventions that correlate to a specific preventive care measure, the applicable NQF number is noted parenthetically. Practices may find assigning responsibility for each of these interventions to specific staff members helpful in integrating each activity into the practice workflow. Technical information regarding specific diagnoses and procedures associated with preventive care measures can be found in the Meaningful Use portal of USHIK.

Key Clinical Interventions
  • Confirm patient's date of birth (all)
  • Record date and type of visit (all)
  • Check patient record for hysterectomy (NQF# 0032; CMS124v7)
  • Check patient record for recent Pap test and, if appropriate, schedule one (NQF# 0032; CMS124v7)
  • Check patient record for a bilateral or unilateral mastectomy (NQF# 2372; CMS125v7)
  • Check patient record for recent mammogram, or if appropriate, schedule one (NQF# 2372; CMS125v7)
  • Check patient record or assess patient for indication of sexual activity (NQF# 0033; CMS153v7)
  • Check patient record or ask patient if a pregnancy test has been performed (NQF# 0033; CMS153v7)
  • Check patient record or ask patient if they received retinoid medication or an x-ray within 7 days of the pregnancy test, if applicable (NQF# 0033; CMS153v7)
  • Check patient record for chlamydia test, or perform one if appropriate (NQF# 0033; CMS153v7)
  • Check patient record for a total colectomy or diagnosis of colorectal cancer (active, inactive, or resolved) (NQF# 0034; CMS130v7)
  • Check patient record for a colonoscopy, flexible sigmoidoscopy, or fecal occult blood test. Schedule a screening test if appropriate (NQF# 0034; CMS130v7)
  • Determine height, weight, and body mass index (BMI) at beginning of physical examination (NQF# 0024; CMS155v7)
  • Check patient record for vaccination records, if appropriate, administer needed vaccinations (NQF# Not Applicable; CMS127v7)
  • Query patient about tobacco use, if appropriate, prescribe tobacco cessation counseling or pharmacotherapy (NQF# 0028; CMS138v7)
  • Determine which medications the patient is currently taking, and make sure they are documented in the medical record (NQF# 0419; CMS68v8)
  • Check patient record for LDL-C test (NQF# TBD)
  • Check patient record for blood pressure assessment, if appropriate, order blood pressure screening (NQF# TBD)
  • Check patient record for depression screening, if appropriate, perform one (NQF# 0418; CMS2v8)

Numerator Elements


This table specifies the information that needs to be documented in the electronic health record to appropriately calculate the numerator. The specific measure to which the element applies in noted by the NQF number in parentheses. Technical information related to the measure numerators can be found in the Meaningful Use portal of USHIK.

Elements Needed for the Numerator

Denominator Elements


This table specifies the information that needs to be documented in the electronic health record to appropriately calculate the denominator. These elements apply to all Meaningful Use preventive care measures. Technical information related to the measure denominators can be found in the Meaningful Use portal of USHIK.

Elements Needed for the Denominator

Exclusion/Exception Elements


This table specifies the information that needs to be documented in the electronic health record to appropriately determine measure exclusions. These elements apply to all Meaningful Use preventive care measures. Technical information related to the measure exclusions/exceptions can be found in the Meaningful Useportal of USHIK.

Elements Needed for Exclusions/Exceptions
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