Tracking and Improving Screening for Colorectal Cancer Intervention

5.d-1 Chart Audit Review Form

CRC Screening Chart Audit Form

Instructions: Use this form to document information on each of four colorectal cancer screening tests (stool test, flexible sigmoidoscopy, barium enema x-ray, and colonoscopy) found in the medical chart. Each test has its own section for you to document your findings.

  • If there is no evidence of a given test being performed, check "no" to the first question for that test and skip to the next section.
  • If a given test was performed more than once since date indicated, document the most recent test.
  • For each type of test performed, document the date of the test, its result, its reason, and where in the chart (or elsewhere) you found the information.
Auditor ______________________ Audit Date ___ / ___ / ___
Patient Study ID # ______________________ Patient Transferred ______________________
Practice ID # ______________________ Patient Deceased ______________________

 

PATIENT DEMOGRAPHICS

Patient Gender: ___ Male ___ Female ___ Missing/Unknown  
Preferred Language: ___ English ___ Spanish ___ Other ___ Missing/Unknown
Marital Status: ___ Single ___ Married ___ Divorced, Separated, Widowed ___ Missing/Unknown
Ethnicity: ___ Hispanic or Latino ___ Non-Hispanic or Non-Latino ___ Missing/Unknown

Race (Check all that apply):

___ American Indian or Alaska Native

___ Asian

___ Black or African American

___ Native Hawaiian or Other Pacific Islander

___ White

___ Other (specify ______________________

___ Missing

Section A. Stool Test (ST)

A-1. Evidence ST was performed since XX/XX/XXXX?

___ Yes     ___ No (skip to next section)

A-2. Most recent ST

Result Date ___ / ___ / ___ (MM/DD/YY)

Result
___ Normal
___ Abnormal (specify) ______________________
___ Missing/Unknown

Reason
___ Screening Test
___ Diagnostic Test
___ Missing/Unknown

A-3. Information found in (Check all that apply)
___ Flow Sheet
___ Progress Note
___ Consults
___ Labs
___ Other (including other than medical chart) specify: ______________________

Section B. Flexible Sigmoidoscopy (FSig)

B-1. Evidence FSig was performed since XX/XX/XXXX?

___ Yes      No (skip to next section)

B-2. Most recent FSig

Result Date ___ / ___ / ___ (MM/DD/YY)

Result
___ Normal
___ Abnormal (specify) ______________________
___ Missing/Unknown

Reason
___ Screening Test
___ Diagnostic Test
___ Missing/Unknown

B-3. Information found in (Check all that apply)
___ Flow Sheet
___ Progress Note
___ Consults
___ Labs
___ Other (including other than medical chart) specify: ______________________

Section C. Barium Enema X-Ray (BE)

C-1. Evidence BE was performed since XX/XX/XXXX?

___ Yes      No (skip to next section)

C-2. Most recent BE

Result Date ___ / ___ / ___ (MM/DD/YY)

Result
___ Normal
___ Abnormal (specify) ______________________
___ Missing/Unknown

Reason
___ Screening Test
___ Diagnostic Test
___ Missing/Unknown

C-3. Information found in (Check all that apply)
___ Flow Sheet
___ Progress Note
___ Consults
___ Labs
___ Other (including other than medical chart) specify: ______________________

Section D. Colonoscopy (Cx)

D-1. Evidence Cx was performed since XX/XX/XXXX?

___ Yes      No (skip to next section)

D-2. Most recent Cx

Result Date ___ / ___ / ___ (MM/DD/YY)

Result
___ Normal
___ Abnormal (specify) ______________________
___ Missing/Unknown

Reason
___ Screening Test
___ Diagnostic Test
___ Missing/Unknown

D-3. Information found in (Check all that apply)
___ Flow Sheet
___ Progress Note
___ Consults
___ Labs
___ Other (including other than medical chart) specify: ______________________

Return to Document

Page last reviewed October 2014
Internet Citation: 5.d-1 Chart Audit Review Form. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/crctoolkit/crctool5d1.html