Std Medical Record Audit Tool Template Page 2
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3STD Medical Record Audit Tool
AUDIT DATE: ______________________
County: ______________________________
MONITOR: ________________________
Chart Number
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Provision of Care – Based upon the Current CDC
and NC DPH Published Guidelines
STD History is accurately documented on the
Problem List
Problem list is Up to Date
Did the client receive appropriate care?
Reason(s) for visit are documented
History about current reason(s) for visit have been
documented
Recent antibiotics and present medications are
documented by name and duration of use
Vaccine history is documented if known
HIV status and HIV testing history is documented if
known
Sexual Risk Assessment is complete
“For Women” section is complete
Details of symptom parameters and sexual risk
assessment are described as comments when
required for complete understanding
Physical Examination is complete and documented
Upper body
Lower body
Did the client receive testing appropriate to symptoms
and clinical findings?
Ordered lab procedures are checked and stat lab
results are documented
Clinical impression(s) are documented
Did the client receive treatment appropriate to
symptoms, clinical findings, and testing?
Therapy corresponds with the clinical impression
Prescriptions and refills are noted
Notes section is used as needed to enhance
continuity of care when the client may be seen by a
different provider on future visits
Prevention
Control measures are documented
Instructions and counseling correspond with clinical
impression(s) and therapy
Instructions include follow up plan if applicable
Partner notification plan is documented
Page 2 of 3
N.C. Division of Public Health
Epidemiology Section
Communicable Disease Branch
DHHS EPI STD Medical Record Audit Tool-Draft
March 2013
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