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Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA) Appendix F. Chart Audit Instrument
I. Patient Demographic Information
- Age (years): _________ (if <1, Enter 0)
-
Gender
__ 1 Male
__ 2 Female
-
Race(check all that apply)
__ 1 American Indian / Alaska Native
__ 2 Asian
__ 3 Native Hawaiian or Other Pacific Islander
__ 4 Black or African American
__ 5 White
__ 6 Unknown
|
-
Ethnicity
__ 1 Hispanic or Latino
__ 2 Not Hispanic or Latino
__ 3 Unknown
-
Insurance Status (check all that apply)
__ 1 Private or Managed Care
__ 2 Medicare
__ 3 Medicaid
__ 4 No Insurance / Self Pay
__ 5 Unknown
|
II. Visit Information — Reason for Visit:
- Visit Date (MM/YYYY): ___ ___/20___ ___
-
Documented Risk Factors
(check all that apply)
__ 1 Recent hospitalization (within 1 month)
__ 2 Family member within (last 6 months)
__ 3 Sport team: ____________________________
__ 4 History of MRSA: __________________
__ 5 Eczema
__ 6Other skin condition: ______________________
__ 7 Immunocompromized
(Cancer, HIV, chronic oral steroid use, or
described as immunocompromized)
__ 8 Diabetes
__ 9 None
-
Fever:
a. History of fever: __ 1 Yes __ 0 No
b. Visit temperature ______° __ 1 C __ 2 F
-
Number of skin or soft tissue lesions: ______
a. Describe if no number given.
-
Description of the largest lesion:
a. Location: _________________
(face, neck, trunk, arm, hand, buttock, leg, foot, head, elsewhere)
|
-
Description of largest site continued:
b. Size:
__ 1 < 1 cm
__ 2 1-5 cm
__ 3 > 5 cm
__ 4 Unknown/not documented in chart
|
Yes |
No |
No Mention |
c. Red (erythema) |
1 |
0 |
7 |
d. Swollen (edema) |
1 |
0 |
7 |
e. Warm |
1 |
0 |
7 |
f. Painful/Tender |
1 |
0 |
7 |
g. Fluctuant, yellow or white center, central point or “head” (induration) |
1 |
0 |
7 |
h. Draining Pus (discharge, purulent) |
1 |
0 |
7 |
-
Incision and Drainage(check all that apply)
__ 1 Incision and Drainage
__ 2 Needle Aspiration
__ 3 Referred
__ 4 Manually Expressed
__ 5 Packed
__ 6 Not performed
|
III. Treatment and Follow-up
-
Culture —review the chart for:
__ 1 Obtained
__ 0 Not Obtained
-
If culture was obtained, which of the following was documented (Check all that apply)
__ 1 Final Culture Result:_________________
__ 2 Patient Notification
__ 3 New Prescription, specifiy:________________
__ 0 Not documented in chart
-
Antibiotic Initially Prescribed: __ 1 Yes↓ __ 0 No
1a. If Yes, name(s): _________________________
|
-
Initial Antibiotic justification:
__ 1 Empiric for suspected MRSA
__ 2 Empiric for non-MRSA or Streptococcus
__ 3 Other, specify: _______________________
__ 0 None
-
Scheduled patient follow-up
__ 1 PRN (as needed)
__ 2 Return to clinic scheduled
__ 0 None
-
Patient education (Check all that apply)
__ 1 Documented reasons to follow-up
__ 2 Patient hand-out
__ 3 Verbal teaching
__ 0 None
|
IV. Diagnoses and Billing Codes
1. All ICD-9 Codes for the Visit:
a. ___________
b. ___________
c. ___________
d. ___________
e. ___________
|
2. All CPT Codes for the Visit:
a. ___________
b. ___________
c. ___________
d. ___________
e. ___________
|
V. Subsequent Office Care (next 14 days) and Patient Outcomes
A. Subsequent Office Care:
- Number of return office visits for the same infection(s): _______
- Any additional procedures in the office:
-
If YES, complete section VI |
← __ 1 Yes↓ __ 0 No
- Change in Antibiotic: __ 1 Yes __ 0 No 3a. If Yes, name(s):_________________________
-
Emergency department / urgent care visit:
__ 1 Yes __ 0 No
- Hospitalization: __ 1 Yes __ 0 No
|
B. Patient-reported Outcomes:
- Type of report: __ 1 Diary
__ 2 Telephone Survey
__ 0 None → (STOP, end of audit)
- Number of days until resolution of fever: ____
- Number of days until resolution of infection: ____
-
Reported antibiotic change: __ 1 Yes↓ __ 0 No
4a. If Yes, name(s):_________________________
- Reported Emergency Department Visit:
__ 1 Yes __ 0 No
- Reported Hospitalization: __ 1 Yes __ 0 No
|
VI. Subsequent Visit Information (only answer the following sections if question V.A2. is “YES”)
- Visit Date (MM/YYYY): ___ ___/20___ ___
-
Documented Risk Factors
(check all that apply)
__ 1 Recent hospitalization (within 1 month)
__ 2 Family member within (last 6 months)
__ 3 Sport team: ____________________________
__ 4 History of MRSA: __________________
__ 5 Eczema
__ 6Other skin condition: ______________________
__ 7 Immunocompromized
(Cancer, HIV, chronic oral steroid use, or
described as immunocompromized)
__ 8 Diabetes
__ 9 None
-
Fever:
a. History of fever: __ 1 Yes __ 0 No
b. Visit temperature ______° __ 1 C __ 2 F
- Number of skin or soft tissue lesions: ______
-
Description of the largest lesion:
a. Location: _________________
(face, neck, trunk, arm, hand, buttock, leg, foot, head, elsewhere)
|
-
Description of largest site continued:
b. Size:
__ 1 < 1 cm
__ 2 1-5 cm
__ 3 > 5 cm
__ 4 Unknown/not documented in chart
|
Yes |
No |
No Mention |
c. Red (erythema) |
1 |
0 |
7 |
d. Swollen (edema) |
1 |
0 |
7 |
e. Warm |
1 |
0 |
7 |
f. Painful/Tender |
1 |
0 |
7 |
g. Fluctuant, yellow or white center, central point or “head” (induration) |
1 |
0 |
7 |
h. Draining Pus (discharge, purulent) |
1 |
0 |
7 |
-
Incision and Drainage(check all that apply)
__ 1 Incision and Drainage
__ 2 Needle Aspiration
__ 3 Referred
__ 4 Manually Expressed
__ 5 Packed
__ 6 Not performed
|
VII. Subsequent Treatment and Follow-up
-
Culture —review the chart for:
__ 1 Obtained
__ 0 Not Obtained
-
If culture was obtained, which of the following was documented (Check all that apply)
__ 1 Final Culture Result:_________________
__ 2 Patient Notification
__ 3 New Prescription, specifiy:________________
__ 0 Not documented in chart
- Antibiotic Prescribed: __ 1 Yes __ 0 No 1a. If Yes, name(s):_________________________
|
-
Antibiotic justification:
__ 1 Empiric for suspected MRSA
__ 2 Empiric for non-MRSA or Streptococcus
__ 3 Other, specify:_______________________
__ 0 None
-
Scheduled patient follow-up
__ 1 PRN (as needed)
__ 2 Return to clinic scheduled
__ 0 None
-
Patient education (Check all that apply)
__ 1 Documented reasons to follow-up
__ 2 Patient hand-out
__ 3 Verbal teaching
__ 0 None
|
VIII. Subsequent Diagnoses and Billing Codes
1. All ICD-9 Codes for the Visit:
a. ___________
b. ___________
c. ___________
d. ___________
e. ___________
|
2. All CPT Codes for the Visit:
a. ___________
b. ___________
c. ___________
d. ___________
e. ___________
|
Return to Contents
Page last reviewed October 2014 Page originally created September 2012
Internet Citation: Appendix F. Chart Audit Instrument. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/final-reports/mrsa/nc_mrsaapf.html | |