Diabetes Chart Audit Form
| Department: | Date of Audit: | PF Reviewing: |
| a | b | c | d | e | f | g | h | i | j |
|---|---|---|---|---|---|---|---|---|---|
| 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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| Totals | Total(b)= | Total(c)= | Total(d)= | Total(e)= | Total(f)= | Total(g)= | Total(h)= | Total(i)= | Total(j)= |
| Performance Indicator | Abstraction 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 = |
