Hospital did not meet the vital sign and lab requirements on recently publised Hybrid HWR HSR for reporting period:  07/01/23-06/30/24.  Reviewed the 2025_IQR_Hybrid_HQR_Report_Discharges report and noted the number of files missing CCDEs were the same number that were noted as Included in Measure Calculation = No and did not have vital signs in this report.  When we reviewed the submitted QRDA, the vital signs were in the submitted QRDA and met the timing requirement.  Please see attached screen shots.

Noted this for a few different hospitals already and wondering if CCDEs were considered properly for their submission requirement performance for the encounters that were noted as Included in Measure Calculation = No?