CRC Screening Chart Audit Form
Instructions: Use this form to document information on each of four colorectal cancer screening tests (stool test, flexible sigmoidoscopy, barium enema x-ray, and colonoscopy) found in the medical chart. Each test has its own section for you to document your findings.
- If there is no evidence of a given test being performed, check "no" to the first question for that test and skip to the next section.
- If a given test was performed more than once since date indicated, document the most recent test.
- For each type of test performed, document the date of the test, its result, its reason, and where in the chart (or elsewhere) you found the information.
| Auditor ______________________ | Audit Date ___ / ___ / ___ |
| Patient Study ID # ______________________ | Patient Transferred ______________________ |
| Practice ID # ______________________ | Patient Deceased ______________________ |
PATIENT DEMOGRAPHICS
| Patient Gender: | ___ Male | ___ Female | ___ Missing/Unknown | |
| Preferred Language: | ___ English | ___ Spanish | ___ Other | ___ Missing/Unknown |
| Marital Status: | ___ Single | ___ Married | ___ Divorced, Separated, Widowed | ___ Missing/Unknown |
| Ethnicity: | ___ Hispanic or Latino | ___ Non-Hispanic or Non-Latino | ___ Missing/Unknown |
|
Race (Check all that apply): ___ American Indian or Alaska Native ___ Asian ___ Black or African American ___ Native Hawaiian or Other Pacific Islander ___ White ___ Other (specify ______________________ ___ Missing |
Section A. Stool Test (ST)
A-1. Evidence ST was performed since XX/XX/XXXX?
___ Yes ___ No (skip to next section)
A-2. Most recent ST
|
Result Reason |
A-3. Information found in (Check all that apply)
| ___ Flow Sheet ___ Progress Note ___ Consults ___ Labs ___ Other (including other than medical chart) specify: ______________________ |
Section B. Flexible Sigmoidoscopy (FSig)
B-1. Evidence FSig was performed since XX/XX/XXXX?
___ Yes No (skip to next section)
B-2. Most recent FSig
|
Result Reason |
B-3. Information found in (Check all that apply)
| ___ Flow Sheet ___ Progress Note ___ Consults ___ Labs ___ Other (including other than medical chart) specify: ______________________ |
Section C. Barium Enema X-Ray (BE)
C-1. Evidence BE was performed since XX/XX/XXXX?
___ Yes No (skip to next section)
C-2. Most recent BE
|
Result Reason |
C-3. Information found in (Check all that apply)
| ___ Flow Sheet ___ Progress Note ___ Consults ___ Labs ___ Other (including other than medical chart) specify: ______________________ |
Section D. Colonoscopy (Cx)
D-1. Evidence Cx was performed since XX/XX/XXXX?
___ Yes No (skip to next section)
D-2. Most recent Cx
|
Result Reason |
D-3. Information found in (Check all that apply)
| ___ Flow Sheet ___ Progress Note ___ Consults ___ Labs ___ Other (including other than medical chart) specify: ______________________ |
