SHIP/ICSI Becker, Clay, Otter Tail, and Wilkin Counties' Healthcare Pre-Intervention (Baseline) Chart Audit
Clinic: Time period audited:
Date: # of charts audited: Audit completed by:
Clinic or Audit BMI BMI 18.5 25: BMI >25: NUTRITION Nutrition
Chart Type of BMI Screening shared with Healthy behaviors Advised of risks and/or Assessed for major and minor Screened/ Screening
Number Visit Gender Age Visit date SCREENED Result patient reinforced benefits of losing weight comorbid conditions Asked about Result
KEY TERMS:
At-risk Nutrition: per clinic screening tool
At-risk Physical Activity: per clinic screening tool
At-risk Tobacco Use: any use of a tobacco product
At-risk Secondhand Smoke Exposure: any exposure to secondhand smoke
At-risk (Harmful) Alcohol Use: per clinic screening tool
Page 1 Baseline Data
Healthy Nutrition: At-risk Nutrition: At-risk Nutrition At-risk Nutrition At-risk Nutrition At-risk Nutrition PHYSICAL ACTIVITY Physical Activity Healthy Physical Activity:
Healthy behaviors Advised of risks and/or Assesed readiness At-risk Nutrition Assist: Assist: Arranged: Screened/ Screening Healthy behaviors
reinforced benefits of change to change Ready to change goals negotiated referral(s) made follow-up schedule Asked about Result reinforced
Page 2 Baseline Data
At-risk Physical Activity: At-risk Physical Activity: At-risk Physical Activity: At-risk Physical Activity At-risk Physical Activity: At-risk Physical Activity: TOBACCO USE Tobacco Use Non-Tobacco-user:
Advised of risks and/or Assesed readiness Ready to Assist: Assisted: physical activity Arranged: Screened/ Screening Healthy behavior
benefits of change to change change goals negotiated referral(s) made follow-up schedule Asked about Result reinforced
Page 3 Baseline Data
Tobacco user: Tobacco User: Tobacco User: Tobacco User: Tobacco User: Tobacco User: SECONDHAND SMOKE Secondhand Smoke No Secondhand Smoke
Advised of risks and/or Assesed readiness Ready to Assist: Assisted: Arranged: EXPOSURE Exposure: Exposure:
benefits of change to change change goals negotiated referral made follow-up schedule Screened/Asked about Screening Result Healthy behavior reinforced
Page 4 Baseline Data
Secondhand Smoke Exposure: Secondhand Smoke Exposure: Secondhand Smoke Exposure: Secondhand Smoke Secondhand Smoke Secondhand Smoke Exposure:
Advised of risks and/or Assesed readiness Ready to Exposure: Exposure: Arranged:
benefits of change to change change Assist: goals negotiated Assisted: referral(s) made follow-up schedule
Page 5 Baseline Data
Page 6 Baseline Data