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| FY 2009 Audit Instructions | ||||||||||||||||||||||||||||||||||||||||||||||||||
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5. PERFORMING A MANUAL AUDIT e. Assessment of Diabetes Care & Outcomes, 2009 ITEM DESCRIPTION For the purposes of this audit, a VISIT is defined as any primary care visit, including ER and walk-in clinics. Do not include dental, eye care, patient education, surgery clinics, etc. DEMOGRAPHIC DATA AUDIT DATE: Ending date of the 365 day audit period. Recommended ending date for submitted audit file is 12/31/2008. CHART NUMBER: Must consist only of numbers (no letters, hyphens or other non-numeric characters) DATE OF BIRTH, SEX: Self-explanatory. FACILITY NAME: Enter your facility's name or abbreviation. AREA, SERVICE UNIT and FACILITY codes: Use the official IHS codes ("ASUFAC" codes). This is for confirmation purposes only, since the WebAudit will automatically supply the codes for you. DOES LOCAL COMMUNITY RECEIVE SPDI
GRANT FUNDS? (1) Yes (2) No or (3) Don't know. TRIBAL ENROLLMENT: Enter the 3 digit Tribal code. # OF PTS IN DIABETES REGISTRY: Enter the number of active patients in your diabetes register. If your service unit has multiple facilities participating in the audit, make sure you use the correct sample size (number of active DM patients) for each component. Please take care to assure accuracy on this critical item. DATE of Diabetes Diagnosis: Enter the date the patient was first diagnosed with diabetes. If only the year of diagnosis is stated, enter "07/01" of that year. If only the month and year are stated, enter the 15th of that month. Leave blank if date is unknown. TYPE of Diabetes: Specify if the patient has (1) Type 1 (a.k.a. IDDM, juvenile onset diabetes), or (2) Type 2 (a.k.a. NIDDM, adult-onset diabetes). Keep in mind that not all insulin-using patients have type 1 diabetes - in fact, most of them have type 2 diabetes. If uncertain, mark as (2) Type 2. TOBACCO USE: Current status of tobacco use (cigarettes, chewing tobacco, snuff, etc) taken from the health summary, problem list or flow sheet. Mark (1) Currently uses tobacco, (2) Does not currently use tobacco, or (3) Tobacco use is undocumented. Referred for cessation counseling? [to be completed only if currently uses tobacco]. (1) Yes, if provider documents cessation counseling or referral for cessation counseling during the audit period. (2) No, if no cessation counseling during the audit period, or (3) Refused, if documented that patient declines/refuses cessation counseling efforts. VITAL STATISTICS HEIGHT: Enter height in inches, or in feet and inches. LAST RECORDED WT: Record in pounds. If pregnant, use last non-pregnant weight. A note to re-confirm the value appears during data entry if an adult weight is <60 lbs or >600 lbs. HTN documented (DX or RX): (1) Yes, hypertension diagnosis is on the problem list or visit assessment, or medication for hypertension is prescribed. (2) No documented hypertension diagnosis or meds. Last 3 BLOOD PRESSURES: Record the last 3 blood pressures obtained within the audit period.
EXAMINATIONS ( during audit period)FOOT EXAM: Exam must include evaluation of sensation and vascular status. EYE EXAM: Exam must include a dilated eye exam or stereo fundus photographs. DENTAL EXAM: Must include examination of the gingiva and mucosal surfaces. Dental records may be kept separate from medical records at your facility and will need to be located for review.
EDUCATION (during audit period)From flow sheets, progress notes, PHN referral or consults. DIET INSTRUCTION: Note any mention of diet instruction in the past year and code by provider type: (1) Registered dietitian, (2) Non-R.D., (3) Both, or (4) None. If it is documented that pt. refused diet counseling, select (5) Refused. EXERCISE INSTRUCTION: Note any mention of exercise instruction in the past year. Any GENERAL DM EDUCATION: Note any recorded patient education in the past year on any topic(s) related to diabetes, other than diet or exercise. TREATMENT (at the time of chart review)DM THERAPY: Enter a 1 (Yes) or 2 (No) for
each of the following therapy groups: (2) Insulin (all forms, including insulin aspart (NovoLog), lispro (Humalog), glargine (Lantus), others) (3) Sulfonylureas, including the following:
( 4) Metformin (Glucophage) Note: Select choices 3 and 4 for Glucovance (glyburide + metformin)(5) Acarbose (Precose) or miglitol (Glyset) (6) Glitazones, including pioglitazone (Actos) or rosiglitazone (Avandia) (7) Incretin mimetics (Byetta) (8) DPP4 inhibitors (Januvia, Galvus) (9) Amylin analogues (Symlin) (10) Refuses therapy, or unknown. ACE INHIBITOR/ARB* use: *Both ACE inhibitors and angiotensin II receptor blockers (ARBs) are included here. Examples of ACE inhibitor drugs include:
Examples of angiotensin II receptor blockers (ARBs) include:
I f unsure, check with your pharmacist regarding the ACE inhibitors and angiotensin II receptor blockers used at your facility.ANTIPLATELET Therapy:
(2) Is not on chronic aspirin
or other antiplatelet/anticoagulant therapy, or LIPID LOWERING AGENT* use:
(2) Currently uses (is prescribed) another class of lipid lowering agent, including any of the following:
(3) Currently uses both a "statin" and any other type of lipid lowering agent, (4) Is not currently on a lipid lowering agent, or (5) Refused lipid lowering therapy or had an adverse reaction. IMMUNIZATIONS FLU VACCINE past year: (1) Yes, if administered during the audit period, (2) No, or (3) Refused, if flu vaccine offered but documented refusal noted on medical record. PNEUMOVAX ever: Self-explanatory. Td/Tdap in past 10 years: Self-explanatory. TB STATUS TB Status (PPD): (1) Pos, if last PPD skin test result was positive, or patient has known history of TB, (2) Neg, if Last PPD was negative, (3) Refused PPD skin testing, or (4) Unknown. If PPD Pos, is INH Tx Complete: (1) Yes, if the patient has documentation of at least 6 months of prophylactic INH or at least 12 months of multiple drug therapy documented for active TB, (2) No, if patient has not completed therapy. Include individuals for whom INH therapy was contraindicated. (3) Refused, if it is documented that patient declined therapy. (4) Unknown treatment status. If PPD Neg, Date of last negative PPD: Self-explanatory. ECG DATE OF LAST ECG: Self-explanatory. Leave blank if no ECG has ever been recorded. LABORATORY DATA Hemoglobin A1c: Record the most recent HbA1c value done within the audit period and the date it was drawn. If the HbA1c value exceeds the upper limit of the lab test's range, enter the upper limit of the range (e.g., if value is ">15" then enter "15"). CREATININE: Enter most recent value during audit period. For patients on renal DIALYSIS of any type, enter a notation to that effect in the "Comments" field. Estimated GFR documented during audit period: (1) Yes, if an eGFR was documented on lab slip or elsewhere in the medical record, or (2) No, eGFR was not documented during audit period. eGFR value: if answer to previous question is Yes, provide actual eGFR value. Do not use non-numeric characters (for example, if eGFR value is >60 or <5, then enter 60 or 5, respectively) CHOLESTEROL (TOTAL, HDL, LDL), TRIGLYCERIDES: For each test, enter most recent value during the audit period. If the last value was drawn outside of the audit period, do not record it. Was URINE PROTEIN TESTING performed during audit period: (1) Yes, if any of the 6 tests listed below was performed during the audit period, (2) No, if none of the 6 tests listed below was performed during the audit period, or (3) Refused. If Yes, provide SPECIFIC URINE PROTEIN TESTING done: When selecting from the choices below, look for them in the listed order (i.e., first look to see if a quantitative UACR was done at any time during the audit period. If not, then look to see if a semi-quantitative UACR was done, and so on down the list). Within any given choice, select the most recent test. (1) Quantitative Urinary Albumin:Creatinine Ratio (UACR) (2) Semi-quantitative UACR
(3) Urinary Protein:Creatinine
Ratio (UPCR)
(4) Other quantitative
urine protein test (for example, a 12- or 24-hr urine albumin) (5) Found to have 1+ protein or more on standard UA dipstick
(6) Other non-quantitative test (included in this category are Micral
dipsticks and microalbumin
For choice (1) above, provide the actual value in milligrams of
albumin per gram of DEPRESSION
as an active problem: (1) Yes, if depression is listed on active problem list or
listed as a Purpose of Visit during the audit period, otherwise (2) No. DEPRESSION SCREENING during the audit period: (1) Yes, if provider used PHQ-2, Zung, Beck or similar depression screening scale, or otherwise documented that pt was assessed for possible depression; (2) No, if no documentation of depression screening found; or (3) Refused the depression screen. [OPTIONAL] A LOCAL OPTION QUESTION, if present, will be found at the end of the audit. Read the question carefully and then select the appropriate response. (For more information on the Local Option Question, see the next section).
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