Manual Chart Review Sheet Page 2
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3Manual Chart Review Sheet
Audit Result
Immunizations
Influenza Vaccination 6mo-17yrs: Has the patient had Influenza vaccination
Yes
No
documented during the Report period? (New measure in FY 2016)
Active Clinical Patients age 6 mo-17yrs:
Influenza Vaccination 18+: Has the patient had Influenza vaccination
Yes
No
documented during the Report period? (New measure in FY 2016)
Active Clinical Patients age 18+:
Pneumococcal Immunization 65+: Has the patient had Pneumococcal
Yes
No
vaccination documented ever or if the patient is over 65 do they have a dose
after the age of 65 or within the past 5 years?
Active Clinical Patients age 65+:
Childhood Immunizations: Has the patient received the 4313*314 combination
Yes
No
(4 DTap, 3 Polio, 1MMR, 3 HiB, 3 HepB, 1 Varicella, 4 Pneumococcal), during
the Report period? 3* refers to the Hib vaccine. Depending on the brand, the
child is considered immunized after either 3 or 4 doses of Hib vaccine.
Active Clinical Patients 19-35 months:
Audit Result
Cancer Screening
Pap Screening: Has the patient had a Pap smear documented in the past 3
Yes
No
years or if the patient is 30-64 years of age, either a Pap smear within the past
three years or a Pap smear and an HPV DNA documented within the past five
years?
Female Active Clinical Patients age 24-64:
Mammography Screening: Has the patient had a Mammogram documented in
Yes
No
the past 2 years?
Female Active Clinical Patients age 52-64:
Colorectal Cancer Screening: Has the patient received any of the following
Yes
No
colorectal cancer screenings: Fecal Occult Blood Test (FOBT) or Fecal
Immunochemical Test (FIT) within in the past year; Flexible Sigmoidoscopy
within the past 5 years, Colonoscopy within the last ten years? (Double Contrast
Barium Enema is no longer accepted.)
Active Clinical Patients age 50-75:
Audit Result
Tobacco Cessation
Tobacco Cessation: Has the patient received tobacco cessation counseling,
Yes
No
received a prescription for a tobacco cessation aid, or quit their tobacco use
anytime during the Report period?
Active Clinical Patients identified as tobacco users (smokers or smokeless
tobacco users) or users in cessation:
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