6.  PERFORMING AN ELECTRONIC CHART REVIEW

RPMS and certain other electronic health record systems are capable of extracting audit data from their clinical database, and can create an audit data file.  This eliminates the need to manually review each record and type the data into the WebAudit.  The sections that follow give a brief step-by-step synopsis of the process using the audit capabilities of RPMS’ Diabetes Management System (DMS).  More detailed information is available in the DMS User’s Manual  [from the drop-down list of applications, select "Diabetes Management System"] 

a.  Creating a Data File 

Before beginning to create an audit data file, be sure that the following conditions are met:

• Taxonomies of Medications, Lab Tests, Health Factors, and Education Topics are present, accurate, and complete.
• The diabetes register is up-to-date, or you have created a search template of the active diabetes patients at your facility.

When the above conditions have been met, you can proceed with creating a data file (also referred to as a .rec file).  Once created, the .rec file can be uploaded to the WebAudit (covered in Section 6b).

1.     Go to the Diabetes Management System (DMS) menu and select “Diabetes QA Audit Menu (DA)”.

2.    Select the most recent audit format, which is the 2008 Diabetes Program Audit (DM08). 

         Select “DM08” again to proceed.                       

3.     DMS will then ask you to identify the diabetes register that you are using, and will ask whether your

        community receives SDPI grant funds.

         If you answer yes, it asks for a grant number.

4.     The program next asks for the date of the audit.  The date will be the ENDING date of the audit period. 

        For the audit submitted to DDTP, we encourage you to use the calendar year (in this case, Jan 1 – Dec 31

        2007).  When doing interim audits, other dates may be used but be sure to keep in mind any data entry lag time. 

        For example, if the data entry staff are about 7-10 days behind, it would be best to set your ending date perhaps

        2-3 weeks earlier, rather than using today’s date.

5.     You next select the type of audit sample.  Choices include individual patients, a template of patients

        created elsewhere (from Q-Man, for instance), or members of a register, such as the IHS DIABETES

        register. 

6.     You are offered the option to audit only patients of a particular provider, or only from a particular

         community, if desired.  Almost always the answer would be “No” for the audit submitted to DDTP.

7.     Next, you are given the option of auditing ALL the patients you have selected, or a random sample of the

        patients.  I have selected ALL patients in this example and most commonly you would do the same.

8.     Choose an output option.  To create a data file, choose option 2 “Create EPI INFO file”.  Other available

        outputs include individual patient audit reports, a cumulative audit report, or both individual and

        cumulative audit reports. 

9.     You will be asked to provide a name (3-8 characters) for the data file.  For example, you might type:

         SAMPLE08.  The program will ask if everything is OK to proceed, and then will create a data file

         named SAMPLE08.rec.  

         The newly created file will be placed in the same directory that the data export files are placed.  You

         will probably need the site manager or other IT professional to retrieve the file and forward it to you.

         Keep track of where you put it!   If you have a tendency to be absent minded, you might want to make a

         new folder called “Audit Files” on your desktop or in My Documents.  Then you will have a specific place

         to put the new data (.rec) file.   It is this file that you will upload to the WebAudit.  It is also readable in

         Epi Info, if that is of interest to you.   The next section discusses how to get the file into the WebAudit.