Attachment L - Chart Audit Abstraction Form

Task Order 13: Sample Chart Audit Form on Care Outcomes for (Diabetes)*

P

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

ractice:

Date of review:

Reviewer:

Please note: “in the past 12 months” means 12 months from the date of the chart review, not the date of the patient’s last visit.

Patient Demographics:

1. Patient Number: __________________________

2. Patient DOB: __________________________

3. Patient Gender: __________________________

4. Patient Insurance Type: __________________________

Laboratory

5. Has the A1C been measured in the past 12 months? ❍ Yes ❍ No

6. Enter the patient’s most recent A1C value. __________________________

7. Has the patient received a urine microalbuminprotein screen in the past 12 months?

❍ Yes ❍ No ❍ Unknown ❍ Not Applicable (gross proteinuria)

8. Has a lipid profile been performed in the past 12 months? ❍ Yes ❍ No

9. Enter the patient’s most recent total cholesterol value. __________________________

10. Enter the patient’s most recent LDL cholesterol value. __________________________

11. Enter the patient’s most recent HDL cholesterol value. __________________________

12. Enter the patient’s most recent triglyceride value. __________________________

13. Has the patient’s blood pressure been measured in the past 12 months? ❍ Yes ❍ No

14. Enter the patient’s most recent systolic blood pressure value. __________________________

15. Enter the patient’s most recent diastolic blood pressure value. __________________________

Public reporting burden for this collection of information is estimated to average XX minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Preventive Care

16. Has the patient had a dilated retinal exam by an ophthalmologist or optometrist in the past 12 months? ❍ Yes ❍ No ❍ Unknown ❍ Not Applicable (blindness)

17. Has the patient had a complete foot exam (by visual inspection, monofilament and pulse exam) within the past 12 months? ❍ Yes ❍ No ❍ Not Applicable(bilateral amputee)

18. Has the patient received a flu vaccine in the past 12 months? ❍ Yes ❍ No ❍ Not Applicable (eg allergy, Hx of druginteraction, contraindication)

19. Does the chart reflect a recommendation for aspirin therapy (dose ≥ 75 mg)? ❍ Yes ❍ No ❍ Not Applicable (patient is < 40 years old, potential interaction, contraindication)

20. Has the patient had a nephropathy screening test or is there evidence of nephopathy? ❍ Yes ❍ No ❍ Not Assessed

21. Is the patient a smoker? ❍ Yes ❍ No ❍ Not Assessed

22. Does the chart reflect that the patient has been counseled to stop smoking? ❍ Yes ❍ No ❍ Not Applicable (nonsmoker)

*Focus of intervention will vary by practice so audits forms appropriate to a practice’s specific focus will be developed based on HEDIS indicators or other appropriate indicators recognized by field.