Manual Chart Review Sheet Page 3
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3Manual Chart Review Sheet
Audit Result
Behavioral Health Screenings
Alcohol Screening: Has the patient (female, age 14-46) been screened for
Yes
No
alcohol use, have alcohol-related diagnoses, or have received alcohol-related
education or counseling during the Report period?
(New Denominator as of FY 2016)
DV/IPV Screening: Has the patient (female, age 14-46) been screened for or
Yes
No
diagnosed with intimate partner/domestic violence at any time during the Report
period?
(New Denominator as of FY 2016)
Female Active Clinical Patients age 14-46:
Depression Screening: Has the patient been screened for depression or
Yes
No
diagnosed with mood disorder at any time during the Report period?
Active Clinical Patients 18+ (note, this should be the same number of
patients as the Influenza 18+ denominator):
Audit Result
HIV Screening
HIV Screening: Has the patient received HIV screening at any time before the
Yes
No
end of the Report period? (New measure in FY 2016)
User Population Patients age 13-64 with no recorded HIV diagnosis prior to
the Report Period:
Audit Result
Breastfeeding Rates
Breastfeeding: Was the patient exclusively or mostly breastfed at age 2
Yes
No
months?
Active Clinical Patients (30-394 days old) screened for feeding choice at
age 2 months (45-89 days old):
Audit Result
Childhood Weight Control Group
CWC: Does the patient have a BMI > or = 95th percentile?
Yes
No
Active Clinical Patients age 2-5:
Keep all chart audits for the audit review process.
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