CMS 117 - Childhood Immunization Status

CMS117v5 (2017)

CMS117v6 (2018)

CMS117v7 (2019)

Description:  Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.

Initial Patient Population:  Children who turn 2 years of age during the measurement period and who have a visit during the measurement period.

Denominator:  Equals Initial Population

Numerator: Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday.

Inverse Measure:  No

Clinical Instructions

Ensure all children turning 2 years of age during the measurement period have had a visit and received the necessary immunizations. Recording the receipt of the immunizations or the admnistration of the vaccines can be done within or outside of an encounter:

  • Option 1: Record the Receipt of Immunizations (Historical)
    • Within Encounter
      • Open the Immunizations/Injections section of the encounter
      • Using the Description autocomplete, begin typing the name of the immunizations
      • Add the Date and any Reactions/Comments
      • Click the Add button
      • Click the Next button, or close the section
      • Continue documenting the encounter as needed
      • When completed, Close and Archive the encounter.
    • Outside Encounter
      • While in the chart, navigate to MAR/Injections from the Medical Record chart tab
      • Click the Quick Add link in the upper-right of the page
      • Record any historical injections
      • Click the Submit button
  • Option 2: Document the Administration of the Vaccines
    • Within Encounter
      • Open the Tests and Procedures section of the encounter
      • Using the autocomplete, begin typing the name of the vaccination being administered
      • Click the Add to Exam button
      • After adding the new section, open the section and fill in all required fields
      • Click the Next button, or close the section
      • Continue documenting the encounter as needed
      • When completed, Close and Archive the encounter
    • Outside Encounter
      • While in the chart, navigate to MAR/Injections from the Medical Record chart tab
      • Click the Add Imm/Inj link in the upper-right of the page
      • Fill in all required fields
      • Click the Submit button

Evidence

Name Value Set
Diagnosis 2.16.840.1.113883.3.464.1003.199.12.1032
Diagnosis 2.16.840.1.113883.3.464.1003.199.12.1031
Diagnosis 2.16.840.1.113883.3.464.1003.199.12.1026
Diagnosis 2.16.840.1.113883.3.464.1003.120.12.1001
Diagnosis 2.16.840.1.113883.3.464.1003.114.12.1007
Diagnosis 2.16.840.1.113883.3.464.1003.110.12.1024
Diagnosis 2.16.840.1.113883.3.464.1003.110.12.1025
Diagnosis 2.16.840.1.113883.3.464.1003.120.12.1003
Diagnosis 2.16.840.1.113883.3.464.1003.199.12.1056
Diagnosis 2.16.840.1.113883.3.464.1003.108.12.1009
Diagnosis 2.16.840.1.113883.3.464.1003.110.12.1053
Diagnosis 2.16.840.1.113883.3.464.1003.110.12.1032
Diagnosis 2.16.840.1.113883.3.464.1003.110.12.1037
Diagnosis 2.16.840.1.113883.3.464.1003.120.12.1007
Diagnosis 2.16.840.1.113883.3.464.1003.110.12.1039
Encounter, Performed 2.16.840.1.113883.3.666.5.307
Encounter, Performed 2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed 2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed 2.16.840.1.113883.3.464.1003.101.12.1024
Encounter, Performed 2.16.840.1.113883.3.464.1003.101.12.1022
Intervention, Order 2.16.840.1.113762.1.4.1108.15
Intervention, Performed 2.16.840.1.113762.1.4.1108.15
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1073
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1033
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1060
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1059
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1062
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1061
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1064
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1063
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1067
Laboratory Test, Performed 2.16.840.1.113883.3.464.1003.198.12.1066
Patient Characteristic Ethnicity 2.16.840.1.114222.4.11.837
Patient Characteristic Payer 2.16.840.1.114222.4.11.3591
Patient Characteristic Race 2.16.840.1.114222.4.11.836
Patient Characteristic Sex 2.16.840.1.113762.1.4.1
Procedure, Performed 2.16.840.1.113883.3.464.1003.110.12.1022
Procedure, Performed 2.16.840.1.113883.3.464.1003.110.12.1043
Procedure, Performed 2.16.840.1.113883.3.464.1003.110.12.1041
Procedure, Performed 2.16.840.1.113883.3.464.1003.110.12.1042
Procedure, Performed 2.16.840.1.113883.3.464.1003.110.12.1045
Procedure, Performed 2.16.840.1.113883.3.464.1003.110.12.1044
Procedure, Performed 2.16.840.1.113883.3.464.1003.110.12.1031
Procedure, Performed 2.16.840.1.113883.3.464.1003.110.12.1046
Procedure, Performed 2.16.840.1.113883.3.464.1003.110.12.1040

Source(s)

Medical Codify

WebChart Documentation
Last Build: Wed, 08 Sep 2021 00:25:58 EDT Legacy Documentation