Chart Audit Form

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Exhibit 4-J
Chart Audit Form
CPA______________________________
Date of Review_____________________
Reviewer__________________________
Page_____of_____
Pg, PP, BF, I, C
Pg, PP, BF, I, C
Pg, PP, BF, I, C
Pg, PP, BF, I, C
Pg, PP, BF, I, C
Pg, PP, BF, I, C
WIC Type
Type of Visit (Cert, Recert, Midcert,
Additional Ed.)
Participant ID Number
Date of Contact
A. Medical
1. Height and weight recorded
2. Hematological result recorded (or “Reason
Blood Work was not Collected” used correctly)
3. Referral medical data, if used, was collected
within acceptable timelines
4. Nutrition Assessment completed
5. Risk Code Assignment
a. Assigned risk codes meet criteria
b. Support for risk code assigned is apparent
in the chart
6. Participant and CPA Signatures obtained for
certification
*Quality Assurance items. Other items (those without *) are part of the WIC Federal Regulations.
4.J-1
9/7/11

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