Clinical Chart Audit Template

Community Health Systems, Inc.Pediatric Chart Review

Community Health Systems, Inc.Pediatric Chart Review <18

Quarter :Clinic: Key

Reviewer: 1=Yes 0= No N=N/ADate:

1 2 3 4 5

Age

Gender

A. Demographics / Consents- Front Office1.Biographical information is documented2. Primary language and linguistic service 3. Emergency contact is identified4, Phone number updated at each visit5. Privacy Notice 6.Consent for treatment7. Release of medical information8. Informed consent for invasive procedure

PercentagePoints Given 0 0 0 0 0 0

#DIV/0!Total Points 0 0 0 0 0 0

B. Vitals- Nursing

3. Head Circumfance

5. Weight taken and plotted on appropriate growth chart6. BMI Percentile



C: Intake- Nursing1. Chief complaint

3. Birth related Hx ( Pediatrics only)

6. Surgical history7. Family History

9. : if pt smokes was education given10. Drug and alcohol hx11. Injury screening and education12. Violence screening and education

1. Blood pressure ( 2 yrs and >) is measured at each visit2. : if BP was high or pt on BP meds was education given?

4. Length/height (recumbent length /standing height) taken and plotted on appropriate growth chart

7. : if overweight or underweight was education given and a plan made

2. Allergies and adverse reactions are prominently noted

4. Heath-related conditions /Medical hx ( e.g. chronic problem list)

5. Medication list ( name, route (including INH and creams), dosage, and frequency

8. Tobacco assessment (Smoking cessation/ Smoking status Annually)


1 2 3 4 513. Sleep position ( infants only)



D. Pediatrics Preventative Screening – Physician1. History and physical (H&P)

3. Subsequent Periodic IHEBA4. Lead questionnaire

7. Developmental Screening8.Behavior screening9.Health education/anticipatory guidance10.. Age appropriate referral to WIC



2.Floride use approprate for age

4. Pap smear on sexually active females

7. Blood Lead Screening Test8. Tuberculosis Screening9. Hgb/hct ( all ages)10. Urine dipstick



2. Vaccine administration documentation3 Vaccine Information Statement (VIS) documentation4. HepB5. RV6. DTaP7. Hib8. Pneumococcal

2. Individual Health Education Behavioral Assessment (IHEBA)

5. Well-child exam completedat age appropriate frequency

6. Nutritional assessment completed ( all pediatrics must have)or detailed list of dietary intake

11. Sexual Active Females: Familly planning Screening ( cousling, referral or Services documented (CHDP/PACT)

E. Pediatric Annual Test- Physician

1. Documentation of dental assessment and annual dental referrals for all children 3 yrs and older

3. STI screening on all sexually active adolescents, incl. Chlamydia for females

5. Vision screening ( snellen test or equivalent) is completed and documented at each well child visit

6. Hearing screening (snellen test or equivalent) is completed and documented

F. Immunizations– Nursing 1. Immunization summary page is present includes consolidation of IZS from other sources


1 2 3 4 59. IPV10. Influenza11. MMR12. Varicella13. HepA14. Meningoccal15. Tdap 16. HPV 17. Mantoux skin test



G. Related Risk

2. All entries are signed, cosigned if applicable dated

4. Plan of Care with each visit

7. Abnormal reports are reviewed and documented.

9. Chart is Organized

11. Chart contents are securely fastened.

13. Member identification is on each page.Percentage

Points Given 0 0 0 0 0 0#DIV/0!

Total Points 0 0 0 0 0 0

Grand TotalPoints Given 0 0 0 0 0 0

#DIV/0!Total Points 0 0 0 0 0 0Percentage % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

1. Errors are corrected according to medical documentation standards (single line, Initials, date, Error)

3. Follow-up instructions and time frame for a return visit or other follow-up care documented at each visit

5. Consults, referral, diagnostic test results, and diagnostic reports have explicit notation in the medical record.

6. Test results/ diagnostic reports and discussion with parents(s), legal guardian, and /or child/youth have explicit notation in the medical record.

8. Missed appointments and follow-up contacts/outreach efforts are documented

10. Date and Initals of staff noted after each entry (multi entry pages)

12. Member’s assigned primary care physician (PCP) is identified.

Community Health Systes, Inc.

Adult Chart Review >18Quarter:

Clinic: Key


1 2 3 4 5Age

GenderA. Demographics / Consents- Front Office

1.Biographical information is documented

2. Primary language and linguistic service

3. Emergency contact is identified

4, Phone number updated at each visit5. Privacy Notice 6.Consent for treatment7. Release of medical information8. Informed consent for invasive procedure9. HIV Consent ( if HIV testing is in chart)10. Advance Directives PercentagePoints Given 0 0 0 0 0 0


B. Vitals- Nursing

3. Height 4. Weight 5. BMI Percentile




5. Surgical history6. Family History

1. Blood pressure ( 2 yrs and >) is measured at each visit

2. : if BP was high or pt on BP meds was education given?

6. : if overweight or underweight was education given and a plan made




8. : if pt smokes was education given9. Drug and alcohol hx10. Injury screening and education

11. Domestic Violence screening and Abuse ScreeningPercentage



D. Adult Preventative Screening – Physician1. Yearly physical2. History and physical (H&P)

4. Subsequent Periodic IHEBA

5. Tuberculosis Screening



1. Colorectal Screening

3. Cervical Cancer Screening/ Pap smear4. Chlamydia screening

5. Breast Cancer Screening 6. Bone Density tests ordered > 65 yrs.

8.HgbA1c ordered semi-annually(Diabetics )

10. Opthamology(Diabetics )11.Dental Referral





6. Familly planning Screening ( cousling, referral or Services documented (CHDP/PACT)

7. Physcocial Hx: Depression Screening Annually ( Diabetics)

E. Adult Annual Test- Physician

2. Males: Prostrate testing/ PSA ordered (males >40yrs)

7. Lipid Disorders Screening Lipid panel ordered semi-annuallys(Diabetics )

9. Foot Exam, monofilament test, year.(Diabetics )

F. Immunizations– Nursing

1. Immunization summary page is present includes consolidation of IZS from other sources

2. Vaccine administration documentation

4. Pneumococcal (Diabetics )5. Influenza or Refusal (Diabetics )6. Varicella7. Meningoccal8. Tdap9. HPV 10. Mantoux skin test



G. Related Risk

2. All entries are signed, cosigned if applicable dated





13. Member identification is on each page.Percentage




#DIV/0!Total Points 0 0 0 0 0 0Percentage % #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

3 Vaccine Information Statement (VIS) documentation

1. Errors are corrected according to medical documentation standards (single line, Initials, date, Error)







Community Helath Systems, Inc.

OBGYN ReviewMonth of:

Clinic:Key


1 2 3 4 5Age

GenderA. Demographics / Consents- Front Office

1.Biographical information is documented

2. Primary language and linguistic service

3. Emergency contact is identified

4, Phone number updated at each visit5. Privacy Notice 6.Consent for treatment7. Release of medical information8. Informed consent for invasive procedureHIV consent ( if HIV lab results are in chart)



B. Vitals- Nursing1. Blood pressure is measured at each visit

3. height

4. Weight 5. Fundal Height




2. : if BP was high or pt on BP meds was education given?



6. Surgical history

7. Pregnacy Hx/ Birth HX

8. : if pt smokes was education given9. Drug and alcohol hx10. Injury screening and education

Percentage



D. OBGYN Screening – Physician

1. Obstetrical and Medical History

3. Subsequent Periodic IHEBA

5. Physcial Exam : includes breast and pelvic exam

7. Third Trimester Comprehensive Re-asssesment

9. Nutritional assessment completed

10. Psychosocial11. Health education12. WIC referral 13. Infant Feeding plans ( prenatal)14. Infant Fedding Status ( postpartum)

Percentage





11. Domistic Violence screening and Abuse Screening


4. Familly planning Screening ( cousling, referral or Services documented (CHDP/PACT)

6. Second Trimester Comprehensive Re-assessment

8. Postpartum ComprehensiveAssessment

Prenatal care visit periodicity according to most recent ACOG standards

2. STI screening , incl.

4. hemoglobin/hematocrid

5.. Urinalysis and urine culture

6. ABO blood group and RH type7. Tuberculosis Screening8. Strep B Screeing

Percentage



2. Vaccine administration documentation

4. HepB or Titer (first trimester)5. Rubella or Titer 6. Influenza7. Varicella8. Meningoccal9. Tdap10 HPV

11. Mantoux skin test

Percentage



G. Related Risk

E. OBGYN Tests- Physician

1. Documentation of dental assessment and annual dental referrals to dentist

3. Chlamydia testing for females with high risk or during the first prenatal visit

9. HIV testing offered ( if postive, HIV information and Couseling is offered) 10, AFP/Genetic Screening Offered

F. Immunizations– Nursing

1. Immunization summary page is present includes consolidation of IZS from other sources

3 Vaccine Information Statement (VIS) documentation




13. Member identification is on each page.

Percentage





Percentage % ### #DIV/0! ### ### ### ###

1. Errors are corrected according to medical documentation standards (single line, Initials, date, Error)2. All entries are signed, cosigned if applicable dated








Community Health Systems, IncChart Audit Dashboard

Clinic: Month/Year: Quarter:

Section a b c d e f gScore #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!



Given Total Points %Peds 0 0 #DIV/0!Adult 0 0 #DIV/0!OBGYN 0 0 #DIV/0!

a b c d e f g

0%200%400%600%800%

1000%

Pediatic Chart Review

a b c d e f g

0%

200%

400%

600%

800%

1000%

Adult Chart Review

a b c d e f g

0%

200%

400%

600%

800%

1000%

OBGYN Chart Review

Community Health Systems, IncChart Audit Dashboard

0 0 #DIV/0!Overall Score

Community Health Systems, Inc.Chart Audit Form

Clinic: Date:

Ped Adult OBGYN □ □ □ Physcian #: Pt # : Patient Name: Age: Gender: DOB:

Issues:A. Demographics / Consents

B. Vitals- Nursing

C: Intake- Nursing

D. Preventative Screening – Physician

E. Annual Test- Physician

G. Related Risks

Medical Director Review

Reviewer:Recommendations

Risk Management Review OnlyRisk Manager: Physcian : Date: Date:

Comments

F. Immunizations

Documents

Clinical Chart Audit Template