Spreadsheet: 08be551e-54e6-40fb-a4be-b0fc3f55b3ad
Sheet: Medical Chart Audit 

Date of Review_____________________ | Scoring: 0 = Out of Compliance; 4 = Out of Compliance (? Risk); 6 = Out of Compliance (No Risk); 8 = Could be more Compliant; 10 = In Compliance |  |  |  |  |  |  |  |  |  |  |  |  |  | Do NOT edit | Do NOT edit
Facility___________________________ | [NAME] | Comments | [NAME] | Comments | Chart number ↓ | Comments | [NAME] | Comments | [NAME] | Comments | Total Points | Percentage Score |  |  | Fields used | Pts possible (based on fields used)
Reviewer_________________________
Age →
BMI →
Contraceptive Method →
Client information
Client's name/ID on each page
Where and how to contact/includes emergency contact information
History includes documentation of (male/female): Complete medical history obtained at initial  visit/updated at subsequent visits
Allergies/reaction to drugs documented
Significant illness, hospitalizations, surgery, exposure to blood products, chronic or acute medical problems
Current use of medication
Use of tobacco, alcohol, drugs
Immunization/Rubella/ HPV
Pertinent family history
HIV risk (IV drug use; MSM, money or drugs for sex; blood transfusion before 1986; recipient of artificial insemination, bone or tissue transplant; dx with other STI(s); multiple partners)
Partner(s) history (injectable drug use, multiple partners, STD/HIV risk history, bisexuality)
Reproductive history (female)
Contraceptive use past/present
Menstrual, LMP, sexual, OB, gyn history
STI/including HIV and HBV
Pap test history
DES, if applicable
Reproductive history (male)
Sexual history
STI, including HIV and HBV
Urological conditions
Physical exam (female)
Height, weight, BMI, BP
If indicated: thyroid, heart, lungs, breasts, abdomen, speculum and bimanual exam, extremities, rectal exam (18 and younger, exam only if indicated; 19 and 20 years old, pelvic exam only if indicated)
Physical exam (male)
If indicated/requested: height ,weight, BMI, BPthyroid, heart, lungs, breasts, abdomen, genitalia, extremities, rectal exam
Lab tests
Ordered per method requirement
As indicated by history
Pap test starting at 21 yo; q 2years 21 - 30 yo; q 2-3- years 30 and older if meet criteria.
CT/GC test if female < 25 years old
If CT/GC test done for > 25, done for risk factors: new partner in last 60 days; multiple sex partners in past 60 days; positive CT in past 3 months; symptomatic for MPC, PID, urethral discharge; STI contact.
If at risk for HIV, referred for testing or tested for HIV
Health maintenance testing (BS, cholesterol, HGB)
Notification and follow up for abnormal results
Assessment
Appropriateness of method choice; consistent with abnormal lab work, referral(s) made
Treatment/special instructions
Revisit recommendation according to method documented
3 month method evaluation after new start documented with appropriate history and assessment
Diagnostic/therapeutic orders correctly written: including name of medication, dosage, route, amount dispensed
FOBT for women > 50years old                                    Offer to men > 50 years old
Continuing care/referral/follow-up
Complete, legible, accurate
Signed by clinician/staff include name, title, date
Education/counseling documented
All methods
Specific method
Emergency contraception
BSE/TSE offered
Prevention counseling HIV/STI
Basic female/male anatomy
Pre-conception counseling if indicated
General nutrition
Weight loss if BMI > 25
Folic acid
Calcium if DMPA
Smoking cessation
Importance of annual flu vaccine
Alcohol/drug abuse if applicable
Adolescent counseling
All methods
Assured confidentiality
Family participation
Sexual coercion
Mandatory report made if indicated
Abstinence
Consents
Program Consent/HIPAA consent
Method Consent
Other
Sterilization counseling/consent
Infertility counseling/exam/referral
Pregnancy diagnosis and counseling
Totals