Post-Activity Practice Improvement Chart Audit

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PRACTICE I MPROVEMENT C HART A UDIT T OOL ( POST)

(For C hart A udits # 11-‐20)

Physician N ame______________________________

Use t his t ool t o r ecord i nformation r egarding 1 0 a dult p atients f or w hom y ou’ve p rescribed o pioids. A lthough n ot a n a bsolute r equirement, i t i s p referred t hat t hese p atients

be c onsecutive. P lease r ecord t he r equested i nformation h ere a nd t hen e nter i nto t he E M P ainline W ebsite a t y our c onvenience. I f y ou h ave a ny q uestions p lease c ontact u s

Did y ou p rovide

written

Date o f

Age Gender

Reason f or V isit

Discharge D iagnosis

Specific O pioid

Quantity

PAT

instructions

Visit

(Choose o ne)