Patient Study ID Number____________
CRC Screening Chart Audit Form
Patient
Study ID No______________ Male______
Female_________
Preferred
Language: ____English ____Spanish ____Other
____Missing
Marital
Status: ____Single ____Married
____Divorced, Separated or Widowed ____Missing
Ethnicity:
____Hispanic or Latino
_____Non-Hispanic or Non-Latino ____Missing Race
(Check all that apply):
____
American Indian or Alaska Native
____ Asian
____ Black or African
American
____ Native Hawaiian or
Other Pacific Islander
____ White
_____Other
specify__________
_____Missing Practice
ID___________________ Auditor_______________________________________
Audit Date _____/_____/_____
MM DD YY
Instructions: Document information on colorectal cancer screening test performance from the medical chart.
If no testing in a category performed, check no result.
If multiple tests were performed in one category, provide information on most recent test.
If the information comes from a source other than the medical chart, indicate the source.
Section A. Stool Test
(ST)- Since < date
A-1. ST Result ___Yes ___No
A-2. Most recent ST ST Result Date ____/____/____
MM DD YY
ST Result ____ Normal
____ Abnormal(specify)_____________________
ST Reason ____ Screening Test
____ Diagnostic Test
____ Unknown
A-3. Source used other than Medical Chart: ____No ____Yes (specify)________________
Section B. Flexible
Sigmoidoscopy (FSig)- Since < date
B-1. FSig Result ____Yes ____No
B-2. Most recent FSig FSig Result Date ____/____/____
MM DD YY
FSig Result ___ Normal
___ Abnormal(specify)___________________
FSig Reason ___ Screening Test
___ Diagnostic Test
___ Unknown
B-3. Source used other than Medical Chart: ____No ____Yes (specify)________________
Section C. Barium Enema
X-Ray (BE)- Since < date
C-1. BE Result ____Yes ____No
C-2. Most Recent BE BE Result Date ____/____/____
MM DD YY
BE Result ___ Normal
___ Abnormal(specify)___________________
BE Reason ___ Screening Test
___ Diagnostic Test
___ Unknown
C-3. Source used other than Medical Chart: ____No ____Yes (specify)______________
Section D. Colonoscopy
(Cx) - Since < date
D-1. Cx Result ____Yes ____No
D-2. Most Recent Cx Cx Result Date ____/____/____
MM DD YY
Cx Result ___ Normal
___ Abnormal(specify)___________________
Cx Reason ___ Screening Test
___ Diagnostic Test
___ Unknown
D-3. Information found in (Check all that apply) ____ Flow Sheet ____ Consults
____ Progress Note ____ Labs
____Other, specify: ________________
D-4. Source used other than Medical Chart: ____No ____Yes (specify)______________
File Type | application/msword |
File Title | CRC Screening Chart Audit Form |
Author | Melanie Johnson |
File Modified | 2008-07-24 |
File Created | 2008-05-29 |