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Osteoporosis PIM Chart Questions _1_

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					                                               Osteoporosis PIM Chart Questions

No.                            Question Text                                                                Responses

      The patient identifier below is for your reference only. Some
      physicians choose to enter a medical record number or
  1                                                                        N/A
      patient initials. Any combination of letters and numbers that
      are meaningful to you may be used.
  2   Patient ID                                                           N/A
      NOTE: For the Patient Visit Date below, enter the most
  3                                                                        N/A
      recent visit date.
  4   Patient Visit Date                                                   N/A
  5   Gender:                                                              [1] Male | [2] Female
  6   Age at the most recent visit:                                        N/A
      Is the zip code of the patient's primary residence documented
  7                                                                        [1] Yes | [2] No
      in the medical record?
  8   5-digit zip code:                                                    N/A
  9   Patient is Hispanic or of Latino origin or descent:                  [1] Yes | [2] No | [3] Unknown
                                                                           [1] White | [2] Black or African American | [3] Asian | [4] Native
 10   Race (check all that apply):                                         Hawaiian or other Pacific Islander | [5] American Indian or Alaska
                                                                           Native | [6] Other | [7] Unknown
      Have language barriers affected your ability to care for this
 11                                                                        [1] Not at all | [2] Somewhat | [3] Greatly
      patient?
                                                                           [1] Private insurance | [2] Traditional Medicare (Part B) | [3] Medicare
                                                                           Advantage/HMO (Part C) | [4] Medicare - type unknown | [5]
      What is the patient's expected source(s) of payment at the
 12                                                                        Medicaid/SCHIP | [6] Worker's compensation | [7] VA, military, or other
      most recent visit, which is listed above? Check all that apply.
                                                                           government | [8] Self-pay (not counting co-payment) | [9] No charge or
                                                                           charity care | [10] Other | [11] Unknown
      Has the patient's health insurance status affected the choices
 13                                                                        [1] Not at all | [2] Somewhat | [3] Greatly
      of care you made for this patient?


                                                                      Page 1.
                                               ABIM PIM Practice Improvement Module®
                                               © American Board of Internal Medicine 2011
                                               Osteoporosis PIM Chart Questions
No.                            Question Text                                                            Responses

 14   Risk Factors                                                      N/A
                                                                        [1] Women age 65 and older | [2] Men age 70 and older | [3] Patients
                                                                        with osteopenia or prior low-impact fracture | [4] Patients on chronic
      Which of the following risk groups for future osteoporotic        oral or parenteral corticosteroid therapy | [5] Patients taking other
      fracture does the patient belong to? (Check all that apply.       medications associated with secondary osteoporosis | [6] Transplant
 15
      Patients must belong to at least one risk group to be eligible    recipients | [7] Women with a history of breast cancer | [8] Men with a
      for inclusion in this chart review.)                              history of prostate cancer | [9] Patients with other conditions
                                                                        associated with an increased risk for osteoporosis | [10] Patients with
                                                                        other risk factors for osteoporosis
 16   Physical Findings                                                 N/A
 17   Is the patient's weight documented in the medical record?         [1] Yes, in pounds | [2] Yes, in kilograms | [3] No
 18   Weight in pounds:                                                 N/A
 19   Weight in kilograms:                                              N/A
      Is the patient's height (from any visit) documented in the
 20                                                                     [1] Yes, in inches | [2] Yes, in centimeters | [3] No
      medical record?
 21   Height in inches:                                                 N/A
 22   Height in centimeters:                                            N/A
                                                                        [1] Underweight (BMI < 18.5) | [2] Normal (BMI 18.5 - 24.9) | [3]
      If both weight and height are not available, what is the
 23                                                                     Overweight (BMI 25 - 29.9) | [4] Obese (BMI >= 30) | [5] Not
      patient's body habitus?
                                                                        documented
 24   Has the patient lost one inch in height or more?                  [1] Yes | [2] No | [3] Not documented
 25   Does the patient have acquired kyphosis?                          [1] Yes | [2] No | [3] Not documented
 26   Diagnostic Testing                                                N/A
      Has the patient ever had a bone mineral density                   [1] Yes | [2] No | [3] Not applicable--patient refuses to consider any
 27
      measurement?                                                      antiresorptive therapy




                                                                   Page 2.
                                               ABIM PIM Practice Improvement Module®
                                               © American Board of Internal Medicine 2011
                                               Osteoporosis PIM Chart Questions
No.                            Question Text                                                             Responses

                                                                         [1] Dual x-ray absorptiometry (DXA) | [2] Peripheral dual x-ray
      Which of the following tests for bone mineral density
                                                                         absorptiometry (pDXA) | [3] Single x-ray absorptiometry (SXA) | [4]
 28   measurement was done? If more than one test has been
                                                                         Quantitative computed tomography (QCT) | [5] Ultrasound
      done, indicate the test done most recently.
                                                                         densitometry | [6] Other
      What was the result of bone mineral density testing? If more       [1] Normal: T-score of -1.0 or greater | [2] Osteopenia: T-score
 29   than one test has been done, provide results for the test done     between -1.0 and -2.5 | [3] Osteoporosis: T-score of -2.5 or less | [4]
      most recently. Report the lowest T-score.                          Not documented
      Is the patient's vitamin D level documented in the medical
 30                                                                      [1] Yes | [2] No
      record?
 31   Modification of Risk Factors for Future Osteoporotic Fractures     N/A
 32   Is the patient a current smoker?                                   [1] Yes | [2] No | [3] Not documented
 33   Is there documentation of smoking cessation counseling?            [1] Yes | [2] No
      Date of the most recently documented smoking cessation
 34                                                                      N/A
      counseling:
                                                                         [1] Brief advice to stop smoking | [2] Support within the office practice |
      During the past 12 months, what type of smoking-cessation          [3] Referral to a smoking-cessation program | [4] Medication (e.g.,
 35
      support has been offered? (Check all that apply.)                  nicotine replacement therapy, bupropion, varenicline) | [5] No support
                                                                         has been offered during the past 12 months | [6] Other
      Does the patient participate regularly in a weight-bearing
 36                                                                      [1] Yes | [2] No | [3] Not documented
      exercise program?
      Is there documentation of advice to start, increase or maintain
 37                                                                      [1] Yes | [2] No
      participation in a weight-bearing exercise program?
      Is the patient's current level of alcohol use documented in the
 38                                                                      [1] Yes | [2] No
      medical record?
      Does the patient engage in potentially hazardous drinking
 39   (more than one drink daily or more than three drinks on any        [1] Yes | [2] No
      occasion)?
      Is there documentation of a screen for falls risk in the past 12
 40                                                                      [1] Yes | [2] No
      months?

                                                                    Page 3.
                                               ABIM PIM Practice Improvement Module®
                                               © American Board of Internal Medicine 2011
                                                Osteoporosis PIM Chart Questions
No.                             Question Text                                                               Responses

      Has the patient fallen more than twice within the past year or
 41                                                                         [1] Yes | [2] No | [3] Not documented
      sustained an injury requiring treatment in a fall?
 42   Has a falls evaluation been done?                                     [1] Yes, complete | [2] Yes, partial | [3] No | [4] Not documented
 43   Pharmacological Treatment and Counseling                              N/A
      Is the patient's current estimated dietary calcium intake
 44                                                                         [1] Yes | [2] No
      documented?
 45   Is the patient currently taking calcium supplementation?              [1] Yes | [2] No | [3] Not documented
      Is the patient currently getting enough calcium through diet
 46                                                                         [1] Yes | [2] No | [3] Not documented
      and/or calcium supplementation?
      Is there documentation of counseling about appropriate
 47                                                                         [1] Yes | [2] No
      calcium intake?
      Is the patient currently getting enough vitamin D through diet,
 48                                                                         [1] Yes | [2] No | [3] Not documented
      supplementation and sun exposure?
 49   Is there documentation of counseling about vitamin D?                 [1] Yes | [2] No
 50   Is patient taking any antiresorptive therapy?                         [1] Yes | [2] No
                                                                            [1] A bisphosphonate | [2] Calcitonin | [3] Estrogen (hormone therapy) |
      Which of the following is the patient currently taking? Check
 51                                                                         [4] Parathyroid hormone | [5] A selective estrogen receptor modulator
      all that apply.
                                                                            (SERM) | [6] Other
 52   Functional Status                                                     N/A
                                                                            [1] Fully active; able to carry on all performance without restriction. | [2]
                                                                            Restricted in physically strenuous activity but ambulatory and able to
                                                                            carry out work of a light or sedentary nature (e.g., light house work,
      Which of the following best describes this patient's current          office work). | [3] Ambulatory and capable of self-care but unable to
 53
      physical functional status (e.g., physical ability)?                  carry out any work activities. Up and about more than 50% of waking
                                                                            hours. | [4] Capable of only limited self-care; confined to bed or chair
                                                                            more than 50% of waking hours. | [5] Completely disabled. Cannot
                                                                            carry on any self-care. Totally confined to bed or chair.
      Is the patient independent in instrumental activities of daily
 54                                                                         [1] Yes | [2] No | [3] Not documented
      living (IADLs)?
                                                                       Page 4.
                                                ABIM PIM Practice Improvement Module®
                                                © American Board of Internal Medicine 2011
                                                Osteoporosis PIM Chart Questions
No.                             Question Text                                                          Responses

 55   Is the patient independent in activities of daily living (ADLs)?   [1] Yes | [2] No | [3] Not documented
 56   Barriers to Self Care                                              N/A
      Is there evidence in this patient's medical record suggesting
 57   that one or more of the following factors limits the patient's     N/A
      ability to engage in self-care?
 58   Psychiatric illness or cognitive impairment                        [1] Yes | [2] No
 59   Problems with adherence                                            [1] Yes | [2] No
 60   Other medical conditions                                           [1] Yes | [2] No
 61   Social factors                                                     [1] Yes | [2] No




                                                                    Page 5.
                                                ABIM PIM Practice Improvement Module®
                                                © American Board of Internal Medicine 2011

				
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