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Integrating Primary Care Practices and Community-based Resources to Manage Obesity

Tool 2. Chart Audit Form and Instructions

(Clinic Name) Chart Review: Screening for Overweight and Obesity

1. Audit Period _____________________________________

2. Patient ID: ______________________   3. Clinic ID: ______________________   4. Assigned PCP ID: ______________________

Patient Demographics

5. Date of birth:______________________    6. Gender: ___ Male  ___ Female

Medical History

7. Which of the following conditions can you confirm for this patient? (Check all that apply.)

___ Arthritis—circle: Osteo or Other ___ Hypertension
___ Asthma ___ Overweight
___ Cancer—specify type(s): ­­­­ ___ Obesity
___ Coronary Artery Disease (CAD) ___ Pregnancy
___ Congestive Heart Failure ___ Pulmonary Embolism
___ Chronic Back Pain ___ Sleep Apnea
___ Depression                   ___ Stroke
___ Diabetes—circle: Type 1 or Type 2 ___ Substance Abuse
___ Dyslipidemia—circle: hyper or hypo ___ None of the conditions listed
___ Gallbladder disease ___ Other weight related—specify: ______________________________________

Weight Management During Audit Period

8. Total Visits During Audit Period: ____________________________________________________________________________

9. Weight Management Tracking

Visit # 1 2 3 4 5 6 7
Date (mm/dd/yy) ___/____/___ ___/____/___ ___/____/___ ___/____/___ ___/____/___ ___/____/___ ___/____/___
Height (in inches) Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2
Weight (in lbs) Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2
BMI Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2
Other weight measures? Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2
Weight discussed? (Circle 1, 2, 3, 4) 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4
Diet discussed? (Circle 1, 2, 3, 4) 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4
Exercise discussed? (Circle 1, 2, 3, 4) 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4 1  2  3  4
Weight Management Referral? Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2 Y1 ____ N2
Other relevant information              

Instructions for Filling Out the Chart Audit

  1. Audit period. Check pre-intervention or post-intervention as appropriate to the audit period you are using.
  2. Patient ID. This should be a unique id number that cannot be linked back to an individual patient. Choose the number and enter.
  3. Clinic ID. This should be a unique id number. Choose the number and enter.
  4. Assigned PCP ID. This is the PCP that is designated as the primary clinician for that patient. This should be a unique id number. Choose the number and enter.
  5. Date of birth. Enter patient DOB as mm/dd/yy.
  6. Gender. Check male or female.
  7. Medical history. Check all conditions that the patient has listed in their medical record. For certain conditions document where additional information is required:
    • Arthritis—circle osteo or other.
    • Cancer—specify type(s).
    • Diabetes—circle Type 1 or type 2.
    • Dyslipidemia—circle: hyper or hypo (note hyperlipidemia, hypercholesterolemia are types of dyslipidemia).
    • Other weight related—specify.

Weight Management Tracking During Audit Period 

  1. Total visits. Write the total number of visits during the audit period here. If there are more than 7 visits during the audit period add a new sheet and continue to track.
  2. Weight Management Tracking
    • Height, Weight, BMI. If these are obtained, circle "Y" for yes and record the value using the units designated (height = inches; weight = lbs.). If these are not obtained circle "N" for no in the appropriate cell.
    • Other weight measures: Some clinics may use alternate means to record weight status such as Body Fat Percentage (BFP), Abdominal Circumference (AC), or Growth Curves (GC). If this is the case, circle "Y" for yes and indicate type. If not circle "N" for no.
    • Weight, diet, exercise discussed. Please circle the appropriate response as follows:
      • 1 = Documented present, current. Chart indicates that the topic was discussed.
      • 2 = Documented not present. Chart indicates that the topic was NOT discussed.
      • 3 = Not documented/unknown. Chart makes no indication if topic was or was NOT discussed.
      • 4 = Documented present, historical. Chart indicates that topic may have been discussed years ago (i.e., appears in history).
    • Weight management referral. If yes, circle "Y" and indicate the name of the organization or individual to which the patient was referred. If no circle "N".
    • Other relevant information. Document anything noteworthy or unclear here, or indicate where this is documented.

Return to Contents

Publication:
14-0043-EF

Page last reviewed May 2014
Page originally created May 2014

Internet Citation: Tool 2. Chart Audit Form and Instructions. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/ncepcr/tools/obesity/obpcp-tool2.html

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