Chart Audit For Prevalence Of Drug And Disease Indicators Page 2
ADVERTISEMENT
1
2
3
4
5Chart #: ______
Screening Form:
Site #:________
Date:___/___/___
Review the patient chart for each of
D
M
Y
the following criteria.
TO BE COMPLETED BY IMPACT
Consider referral to IMPACT
Not included as part of case finding for IMPACT
Not to be considered as part of case finding for IMPACT:
Less than one visit to the family physician in the last 12 months [ ] Yes [ ] No [ ] Don’t Know
More than 20 visits to the family physician in the last 12 months [ ] Yes [ ] No [ ] Don’t Know
Awaiting placement to a nursing home or long-term care…………[ ] Yes [ ] No [ ] Don’t Know
Alcoholism………………………………………………………………[ ] Yes [ ] No [ ] Don’t Know
Palliative care patient……………………………….…………………[ ] Yes [ ] No [ ] Don’t Know
Family physician only sees as a home visit ……………………….. [ ] Yes [ ] No [ ] Don’t Know
(i.e. patient cannot come to the clinic)
If you chose Yes for any of the above criteria, DO NOT collect any further information on this form.
Considered for case finding strategy: referral to IMPACT
Patient has to be 65 years of age or over AND meet either
OR
2 criteria in Section 1
1 criterion each in Section 1 and Section 2
Section 1: Vascular and Symptom Based Criteria
1. Elevated blood pressure- one reading>155/95mmHg or 140/90mmHg in diabetics
2. Elevated - HbA1c >0.075 (7.5%)
3. Elevated LDL-C >3.4mmol/L (F) or >2.6mmol/L (M)
4a. Diagnosis of Hypertension and NO blood pressure readings in the past 12 months OR
b. Diagnosis of Diabetes and NO HbA1c readings in the last 12 months OR
c. Diagnosis of Hyperlipidemia and NO LDL readings in the past 12 months
5. Diagnosis of Osteoarthritis or Rheumatoid Arthritis
6. Using narcotics (codeine, morphine or other as per list)
7. Diagnosis of hypertension, diagnosis of diabetes and not using an ACEI
8. Diagnosis of hypertension, elevated blood pressure and using an NSAID
9. Diagnosis of hyperlipidemia, elevated LDL and not using a lipid lowering agent
10. Diagnosis of hypertension, high blood pressure and not using a potassium wasting diuretic
Section 2: Drug-Based Criteria
1. using an NSAID with NO BUN/Creatinine levels measured in past 12 months OR BUN/creat is elevated
2. using a potassium wasting diuretic with NO potassium levels measured in the past 12 months OR low potassium
3. using ACE-I and NO BUN/Creatinine levels measured in the past 12 months OR BUN/creat is elevated
4. using ACE-I and NO potassium levels measured in the past 12 months OR elevated potassium
5. using phenytoin and drug level is elevated
6. using theophylline and drug level is elevated
7. using lithium and drug level is elevated
8. using digoxin and the drug level is elevated
9. using Estrogen / Hormone Replacement Therapy (ERT)
10. using more than 8 medications
Other
11. More than 2 hospitalizations in past 12 months
IMPACT Project 2006
- 2 -
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For Refund Of Gasoline And Special Fuel Taxes Form - West Virgonia Department Or Tax And Revenue - Internal Auditing Division - Excise Tax Unit
Business
Form Dtf-719-mn - Renewal Application For Registration Of Retail Dealers And Vending Machines For Sales Of Cigarettes And Tobacco Products - New York State Department Of Taxation And Finance
Financial
Form Abl-500 - Application For Producer Of Beer And Wine Certificate Of Registration And Form Abl-569 - Beer And Wine Producers Authorization Of Wholesalers And Brands
Financial
Form Rv-f1302901 - Exemption Certification For Farm Equipment And Machinery And For Purchase Of Electricity And Liquefied Gas At A Reduced Rate - Tennessee Department Of Revenue
Financial
Related Categories
Parent category: Medical