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Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA)

Appendix F. Chart Audit Instrument


I. Patient Demographic Information

  1. Age (years): _________ (if <1, Enter 0)

  2. Gender

    __ 1 Male
    __ 2 Female

  3. Race(check all that apply)
     

    __ 1 American Indian / Alaska Native
    __ 2 Asian
    __ 3 Native Hawaiian or Other Pacific Islander
    __ 4 Black or African American
    __ 5 White
    __ 6 Unknown

  1. Ethnicity

    __ 1 Hispanic or Latino
    __ 2 Not Hispanic or Latino
    __ 3 Unknown

  2. Insurance Status (check all that apply)

    __ 1 Private or Managed Care
    __ 2 Medicare
    __ 3 Medicaid
    __ 4 No Insurance / Self Pay
    __ 5 Unknown

II. Visit Information — Reason for Visit:

  1. Visit Date (MM/YYYY): ___ ___/20___ ___

  2. Documented Risk Factors

    (check all that apply)
    __ 1 Recent hospitalization (within 1 month)
    __ 2 Family member within (last 6 months)
    __ 3 Sport team: ____________________________
    __ 4 History of MRSA: __________________
    __ 5 Eczema
    __ 6Other skin condition: ______________________
    __ 7 Immunocompromized
          (Cancer, HIV, chronic oral steroid use, or
           described as immunocompromized)
    __ 8 Diabetes
    __ 9 None

  3. Fever:

    a. History of fever: __ 1 Yes  __ 0 No

          b. Visit temperature ______°   __ 1 C   __ 2 F

  4. Number of skin or soft tissue lesions: ______

    a. Describe if no number given.

  5. Description of the largest lesion:
     

    a. Location: _________________
    (face, neck, trunk, arm, hand, buttock, leg, foot, head, elsewhere)

  1. Description of largest site continued:

    b. Size:
       __ 1 < 1 cm
       __ 2 1-5 cm
       __ 3 > 5 cm
       __ 4 Unknown/not documented in chart

     YesNoNo Mention
    c. Red (erythema)107
    d. Swollen (edema)107
    e. Warm107
    f. Painful/Tender107
    g. Fluctuant, yellow or white center, central point or “head” (induration)107
    h. Draining Pus (discharge, purulent)107

  2. Incision and Drainage(check all that apply)

    __ 1 Incision and Drainage
    __ 2 Needle Aspiration
    __ 3 Referred
    __ 4 Manually Expressed
    __ 5 Packed
    __ 6 Not performed

 

III. Treatment and Follow-up

  1. Culture —review the chart for:

    __ 1 Obtained
    __ 0 Not Obtained

  2. If culture was obtained, which of the following was documented (Check all that apply)

    __ 1 Final Culture Result:_________________
    __ 2 Patient Notification
    __ 3 New Prescription, specifiy:________________
    __ 0 Not documented in chart

  3. Antibiotic Initially Prescribed: __ 1 Yes↓  __ 0 No

         1a. If Yes, name(s): _________________________

  1. Initial Antibiotic justification:

    __ 1 Empiric for suspected MRSA
    __ 2 Empiric for non-MRSA or Streptococcus
    __ 3 Other, specify:  _______________________
    __ 0 None

  2. Scheduled patient follow-up

    __ 1 PRN (as needed)
    __ 2 Return to clinic scheduled
    __ 0 None

  3. Patient education (Check all that apply)

    __ 1 Documented reasons to follow-up
    __ 2 Patient hand-out
    __ 3 Verbal teaching
    __ 0 None

IV. Diagnoses and Billing Codes

1. All ICD-9 Codes for the Visit:

a. ___________

b. ___________

c. ___________

d. ___________

e. ___________

2. All CPT Codes for the Visit:

a. ___________

b. ___________

c. ___________

d. ___________

e. ___________

V. Subsequent Office Care (next 14 days) and Patient Outcomes

A. Subsequent Office Care:

  1. Number of return office visits for the same infection(s): _______
  2. Any additional procedures in the office:
  3. If YES, complete section VI
    ←      __ 1 Yes↓  __ 0 No
  4. Change in Antibiotic:       __ 1 Yes   __ 0 No      3a. If Yes, name(s):_________________________

  5. Emergency department / urgent care visit:
     

    __ 1 Yes  __ 0 No

  6. Hospitalization: __ 1 Yes  __ 0 No

B. Patient-reported Outcomes:

  1. Type of report:      __ 1 Diary
                                    __ 2 Telephone Survey
      __ 0 None → (STOP, end of audit)
  2. Number of days until resolution of fever:      ____
  3. Number of days until resolution of infection: ____

  4. Reported antibiotic change:    __ 1 Yes↓  __ 0 No

         4a. If Yes, name(s):_________________________

  5. Reported Emergency Department Visit:     
    __ 1 Yes  __ 0 No
  6. Reported Hospitalization:    __ 1 Yes  __ 0 No

 

VI. Subsequent Visit Information (only answer the following sections if question V.A2. is “YES”)

  1. Visit Date (MM/YYYY): ___ ___/20___ ___

  2. Documented Risk Factors

    (check all that apply)
    __ 1 Recent hospitalization (within 1 month)
    __ 2 Family member within (last 6 months)
    __ 3 Sport team: ____________________________
    __ 4 History of MRSA: __________________
    __ 5 Eczema
    __ 6Other skin condition: ______________________
    __ 7 Immunocompromized
          (Cancer, HIV, chronic oral steroid use, or
           described as immunocompromized)
    __ 8 Diabetes
    __ 9 None

  3. Fever: 

    a. History of fever: __ 1 Yes  __ 0 No

          b. Visit temperature ______°   __ 1 C   __ 2 F

  4. Number of skin or soft tissue lesions: ______

  5. Description of the largest lesion:

    a. Location: _________________
    (face, neck, trunk, arm, hand, buttock, leg, foot, head, elsewhere)

  1. Description of largest site continued:

    b. Size:
       __ 1 < 1 cm
       __ 2 1-5 cm
       __ 3 > 5 cm  
       __ 4 Unknown/not documented in chart

     YesNoNo Mention
    c. Red (erythema)107
    d. Swollen (edema)107
    e. Warm107
    f. Painful/Tender107
    g. Fluctuant, yellow or white center, central point or “head” (induration)107
    h. Draining Pus (discharge, purulent)107

  2. Incision and Drainage(check all that apply)

    __ 1 Incision and Drainage
    __ 2 Needle Aspiration
    __ 3 Referred
    __ 4 Manually Expressed
    __ 5 Packed
    __ 6 Not performed

 

VII. Subsequent Treatment and Follow-up

  1. Culture —review the chart for:

    __ 1 Obtained
    __ 0 Not Obtained

  2. If culture was obtained, which of the following was documented (Check all that apply)

    __ 1 Final Culture Result:_________________
    __ 2 Patient Notification
    __ 3 New Prescription, specifiy:________________
    __ 0 Not documented in chart

  3. Antibiotic Prescribed: __ 1 Yes  __ 0 No      1a. If Yes, name(s):_________________________

  1. Antibiotic justification:

    __ 1 Empiric for suspected MRSA
    __ 2 Empiric for non-MRSA or Streptococcus
    __ 3 Other, specify:_______________________
    __ 0 None

  2. Scheduled patient follow-up

    __ 1 PRN (as needed)
    __ 2 Return to clinic scheduled
    __ 0 None

  3. Patient education (Check all that apply)

    __ 1 Documented reasons to follow-up
    __ 2 Patient hand-out
    __ 3 Verbal teaching
    __ 0 None

VIII. Subsequent Diagnoses and Billing Codes

1. All ICD-9 Codes for the Visit:

a. ___________

b. ___________

c. ___________

d. ___________

e. ___________

2. All CPT Codes for the Visit:

a. ___________

b. ___________

c. ___________

d. ___________

e. ___________

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Current as of March 2011
Internet Citation: Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA). March 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/mrsa/nc_mrsaapf.html