Mammogram Audit Form Template by fbx82765

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									          Audit Specifications
Facility Name and Location
ASUFAC
Date of Audit/GPRA Quarter
Auditor's Initials
             GPRA Measure                        Numerator               Denominator                   %           2010 Target*
Diabetes Diagnosed Ever**                                                                           #DIV/0!            N/A
Documented A1c                                                                                      #DIV/0!            N/A
Poor Glycemic Control                                                                               #DIV/0!          Baseline
Ideal Glycemic Control                                                                              #DIV/0!          Baseline
Controlled BP <130/80                                                                               #DIV/0!          Baseline
LDL Assessed                                                                                        #DIV/0!          Baseline
Nephropathy Assessed                                                                                #DIV/0!          Baseline
Influenza 65+                                                                                       #DIV/0!          Baseline
Pneumovax 65+                                                                                       #DIV/0!          Baseline
Childhood Immunization                                                                              #DIV/0!          Baseline
Pap Screening                                                                                       #DIV/0!          Baseline
Mammography Screening                                                                               #DIV/0!          Baseline
Colorectal Cancer Screening                                                                         #DIV/0!          Baseline
Tobacco Cessation                                                                                   #DIV/0!          Baseline
Alcohol Screening (FAS Prevention)                                                                  #DIV/0!          Baseline
DV/IPV Screening                                                                                    #DIV/0!          Baseline
Depression Screening                                                                                #DIV/0!          Baseline
Prenatal HIV Screening                                                                              #DIV/0!          Baseline
Childhood Weight Control                                                                            #DIV/0!          Baseline
*Because of the transition to CRS reporting, 2010 urban targets are to set new baselines for all measures
**Please note: the denominator for the diabetes measures should not be the same as the numerator for the
diabetes diagnosed ever measure. Please refer to the CRS manual for the definition of an active clinical patient
when determining the denominator for all diabetes measures.
Facility Name
ASUFAC
Date of Audit/GPRA Quarter
Auditor's Initials
Diabetes Diagnosis Ever
Documented HbA1c
Poor Glycemic Control
Ideal Glycemic Control
Controlled BP
LDL Assessed
Nephropathy Assessed
Influenza 65+
Pneumovax 65+
Childhood Immunization
Pap Screening
Mammogram
Colorectal Cancer Screening
FAS Prevention
DV/IPV Screening
Depression Screening
Tobacco Cessation
Childhood Weight Control
HIV Screening- Prenatal



Contact Information:
Comments:

Include the entire "official" facility name
Include the official 6 digit Area, Service Unit, Facility Code
Include the date the audit was performed, and the GPRA quarter (2nd or 3rd)
Include any/all initials of those performing chart audits
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically
See GPRA logic for numerator/denominator definitions - % will calculate automatically



E-mail this form to your Area GPRA Coordinator

								
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