Chart Audit For Prevalence Of Drug And Disease Indicators Page 3
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5Screening Form:
Chart #: ______
Site #:________
Review the patient chart for each of the following
Date:__/__/__
criteria. At least two of the boxes should be checked
D M Y
for each criteria.
Section 1: Vascular and Symptom Based Criteria
1. Record HbA1c readings measured in the past 12 months: (if > 3 in past 12 months record 3 most recent readings)
Check ([) if there are no readings in the past 12 months, and proceed to question 2.
Date
HbA1c reading
Elevated (check box if >0.075)
(DD/MM/YY)
Begin with most recent
2. Record blood pressure (BP) readings in the past 12 months: (if > 4 readings in past 12 months record 4 most recent)
Check ([) if there are no readings in the past 12 months, and proceed to question 3.
Date
Systolic (mmHg)
Diastolic (mmHg)
Elevated (>155/95mmHg or 140/90mmHg in diabetics)
(DD/MM/YY)
Begin with most recent
3. Record LDL (cholesterol) readings in the past 12 months and complete the following table:
Check if there are no readings in the past 12 months, and proceed to question 4.
Date
LDL reading
Elevated (female and LDL >3.4 OR
(DD/MM/YY)
Begin with most recent
male and LDL >2.6)
4. Patient has osteoarthritis OR rheumatoid arthritis……………………..[ ] Yes
[ ]No
5. Patient using narcotics (codeine OR morphine)……………………….[ ] Yes
[ ]No
Section 2: Drug Based Criteria
6. Patient using a NSAID……………………………………
[ ] Yes [ ] No
[ ]Don’t Know
(BUN/creatinine measured within 12 months)………….. [ ] Yes [ ] No
[ ]Don’t Know
[ ] Yes [ ] No
[ ]Don’t Know
(Last BUN/Creatinine measurement within 12 mos. is elevated)
7. Patient using a potassium wasting diuretic………………. [ ] Yes [ ] No
[ ]Don’t Know
(potassium measured within 12 months)………………….. [ ] Yes [ ] No
[ ]Don’t Know
[ ] Yes [ ] No
[ ]Don’t Know
(Last potassium measurement within 12 mos. is low)……….…..
8. Patient using Phenytoin …………………………………… [ ] Yes [ ] No
[ ]Don’t Know
(drug level is elevated)…………………………………….. [ ] Yes [ ] No
[ ]Don’t Know
9. Patient using Digoxin………………………………………. [ ] Yes [ ] No
[ ]Don’t Know
(drug level is elevated)……………………………………. [ ] Yes [ ] No
[ ]Don’t Know
10. Patient using Theophylline……………………………….. [ ] Yes [ ] No
[ ]Don’t Know
(drug level is elevated)……………………………………. [ ] Yes [ ] No
[ ]Don’t Know
11. Using ACE I………………………………………………… [ ] Yes [ ] No
[ ]Don’t Know
(BUN/creatinine measured within 12 months)…………… [ ] Yes [ ] No
[ ]Don’t Know
[ ] Yes [ ] No
[ ]Don’t Know
(Last BUN/Creatinine measurement within 12 mos. is elevated)
(potassium level measured within 12 months)……….……[ ] Yes [ ] No
[ ]Don’t Know
[ ] Yes [ ] No
[ ]Don’t Know
(Last potassium measurement within 12 mos. is elevated)…….
12. Using Lithium………………………………………………. [ ] Yes [ ] No
[ ]Don’t Know
(TSH measured in past 12 months)……………………… [ ] Yes [ ] No
[ ]Don’t Know
(drug level is elevated)……………………………………. [ ] Yes [ ] No
[ ]Don’t Know
13. On Estrogen Replacement Therapy…………………….. [ ] Yes [ ] No
[ ]Don’t Know
14. Is the patient taking more than 8 medications?………… [ ] Yes [ ] No
[ ]Don’t Know
Other
15. Was patient hospitalized more than 2 times in past 12 months?…………… [ ] Yes [ ] No
[ ]Don’t Know
IMPACT Project 2006
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