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IHS Diabetes Care & Outcomes Audit
Hosted by Ray Shields, MD
|FY 2010 Audit Instructions|
5. PERFORMING A MANUAL AUDIT
e. Assessment of Diabetes Care & Outcomes, 2010 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.
Audit Period Ending Date: Ending date of the 365 day audit period. Recommended ending date for the audit data submitted to the Division of Diabetes via the WebAudit is 12/31/2009.
FACILITY NAME: Enter your facility's name or abbreviation. This is optional since the WebAudit will provide it automatically, but good to include on the audit forms (or at least the top form), especially if there are other facilities nearby.
REVIEWER: Enter the initials of the person doing the medical chart review (maximum of 3 letters).
TRIBAL enrollment code: Enter the patient's 3 digit Tribal code.
STATE of Residence: Enter the 2 character postal abbreviation for the State in which the person resides. If the person lives outside of the United States (e.g., in Canada), leave blank.
CHART NUMBER: Chart numbers must consist only of numbers (no letters, hyphens or other non-numeric characters)
Date of Birth: Self-explanatory (this is a required element and MUST be entered)..
SEX: Self-explanatory (this is a required field and MUST be entered). 1=Male, 2=Female.
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: List most 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 not documented.
Cessation counseling received? [to be completed only if patient 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.
HEIGHT: Enter height in inches, or in feet and inches. Fractional parts of an inch may be entered in decimal form (for example, 63 1/2 inches = 63.5, 71 3/4 inches = 71.75)
LAST WEIGHT in audit period: 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 in a non-ER setting and within the audit period, up to a maximum of 3 readings. A mean BP will automatically be calculated based on the last 3 BP readings if 3 readings are available, otherwise on the last 2 BPs.
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 by a retinal camera.
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 RD and non-RD, or (4) None. If it is documented that the person refused diet counseling, select (5) Refused.
EXERCISE INSTRUCTION: Note any documentation of exercise instruction during the audit period.
Any Other DM EDUCATION: Note any recorded patient education during the audit period on any topic(s) related to diabetes, other than diet or exercise.
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.
TREATMENT (atthe time of chart review)
DM THERAPY: Mark each choice as 1 (Yes) or 2 (No),
(2) Insulin (all forms, including insulin aspart (NovoLog), lispro (Humalog), glargine (Lantus), others)
(3) Sulfonylureas, including the following:
(4) Sulfonylurea-like medications, including the following:
(5) Metformin (Glucophage) For combination meds such as Avandamet (rosiglitazone + metformin), and Actoplus Met (pioglitazone + metformin), be sure to mark 1(Yes) for both components.
(6) Acarbose (Precose) or miglitol (Glyset)
(7) Glitazones, including pioglitazone (Actos) or rosiglitazone (Avandia)
(8) Incretin mimetics (Byetta)
(9) DPP4 inhibitors (Januvia, Onglyza)
(10) Amylin analogues (Symlin)
(11) 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:
If unsure, check with your pharmacist regarding the ACE inhibitors and angiotensin II receptor blockers used at your facility.
(2) None, Is not on chronic aspirin
or other antiplatelet/anticoagulant therapy, or
LIPID LOWERING AGENT* use:
(1) "Statin" lipid lowering agent, including any of the following:
(2) Fibrate, including any of the following:
(3) Niacin (nicotinic acid)
(4) Bile Acid Sequestrants
(6) Fish Oil (OTC or in-house script from provider)
(7) Omega-3-Acid Ethyl Esters (Lovaza)
(8) None or refused
Most recent TB Test done (that has a valid result):
TB Test result (answer only if response to previous question was (1) or (2)):
If TB test is Positive, is INH Tx Complete:
If TB test is Negative, Date of last negative TB test: Self-explanatory.
DATE OF LAST ECG: Self-explanatory. Leave blank if no electrocardiogram has ever been recorded.
Seasonal FLU VACCINE during audit period: (1) Yes, if seasonal flu (not H1N1) vaccine 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 or DT in past 10 years: Self-explanatory.
Hemoglobin A1c: Record the most recent HbA1c value done within the audit period and the date it was drawn. When entering the result, omit any ">" or "<" signs (for example, >14 is entered as 14).
CREATININE: Enter most recent serum creatinine value (leave blank if no serum creatinine done during the audit period).
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 (in mL/min/1.73m2). Do not use non-numeric characters such as "<" or ">" (for example, if eGFR value is "<5" or ">60", then enter "5" or "60", respectively)
CHOLESTEROL (TOTAL, HDL, LDL), TRIGLYCERIDES: For each test, enter most recent value during the audit period. Leave blank if no test performed during the audit period or if the result is non-numeric such as "N/A" or "Comment: serum too lipemic".
Was URINE TESTED FOR PROTEIN during the 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 refusal of urine testing is documented in the medical record.
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 UACR was done at any time during the audit period. If not, then look to see if a UPCR was done, and so on down the list). Within any given choice, select the most recent test.
(1) Urine albumin:creatinine ratio (UACR) -- for this choice, provide the actual value in mg/g.
(2) Urine protein:creatinine ratio (UPCR) -- for this choice, provide the actual value in g/g.
(3) 24-hr urine collection for protein -- for this choice, provide the actual value in mg/24hrs.
(4) Microalbumin:creatinine strips (e.g., Clinitek) -- for this choice, select the appropriate range:
(5) Microalbumin only (e.g., Micral) -- for this choice, select the appropriate range:
(6) Standard UA dipstick for protein -- for this choice, select from the following results:
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).