Chart Audit For Prevalence Of Drug And Disease Indicators

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Chart #: ______
Chart Audit for prevalence of
Site #:________
drug and disease indicators
Date:___/___/___
D
M
Y
Patient sex:
M
F
Patient age:
________
or DOB (yy.mm.dd) _____________
Date of last visit (yy.mm.dd):
___________________
Physician name:
______________________________________
IMPACT Project 2006
- 1 -

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