Post-Activity Practice Improvement Chart Audit Page 2

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Did   y ou   p rovide  
Did   y ou   p rovide  
written  
written  
Date   o f  
Age   Gender  
Reason   f or   V isit  
Discharge   D iagnosis  
Specific   O pioid  
Quantity  
PAT  
instructions  
instructions  
Visit  
(Choose   o ne)  
(Choose   o ne)  
Prescribed    
Prescribed  
Queried?  
regarding   o pioid  
regarding   o pioid  
(Yes/No)  
(Choose  
(Enter  
storage?  
disposal?  
 
 
strongest   o pioid)  
amount)
(Yes/No)
(Yes/No)
 
16  
17  
18  
19  
20  

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