Module 8 Appendix A

Sample Data Abstraction Form

Diabetes Chart Audit Form

Department:Date of Audit:PF Reviewing:

 

abcdefghij
Pt. ID (do not include names)HbA1c in the past 3 months? 0=NO
1=YES
HbA1c less than 7.0?
0=NO
1=YES
BP documented at last visit?
0=NO
1=YES
BP less than 130/80 mm Hg?
0=NO
1=YES
LDL-C in past 12 months?
0=NO
1=YES
LDL-C less than 100 mg/dL?
0=NO
1=YES
Eye exam in the past 12 months?
0=NO
1=YES
Foot exam in the past 12 months?
0=NO
1=YES
Other indicator (per practice):
0=NO
1=YES
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TotalsTotal(b)=Total(c)=Total(d)=Total(e)=Total(f)=Total(g)=Total(h)=Total(i)=Total(j)=

 

Performance IndicatorAbstraction Result (percent)Goal set by Practice (percent)External Benchmark (percent)
HbA1c screening rate = [Total(b)/30 (total # of charts audited)] x 100 =   
HbA1c less than 7.0 = [Total(c)/Total(b)] x 100 =   
Blood pressure documented = [Total(d)/30 (total # of charts audited)] x 100 =   
Blood pressure less than 130/80 = [Total(e)/Total(d)] x 100 =   
LDL-C screening rate = [Total(f)/30 (total # of charts audited)] x 100 =   
LDL-C less than 100 mg/dL = [Total(g)/Total(f)] x 100 =   
Eye Exams = [Total(h)/30 (total # of charts audited)] x 100 =   
Foot Exams = [Total(i)/30 (total # of charts audited)] x 100 =   
Other indicator (per practice): = Total(j) x 100 =   

 

Return to Module 8

Current as of May 2013
Internet Citation: Module 8 Appendix A: Sample Data Abstraction Form. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod8appendixa.html