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									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 < BMI < 25:            BMI >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

								
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