588 lines
25 KiB
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588 lines
25 KiB
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<title>Appendix F. Chart Audit Instrument | AHRQ Archive</title>
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<p>This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information.</p>
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<article class="grid_9">
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<div >
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<h1 class="page__title title" id="page-title">Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA)</h1> <h2>Appendix F. Chart Audit Instrument</h2>
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</div>
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<div class="field field-name-ahrq-generic-body field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><h3>I. Patient Demographic Information</h3>
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<table border="1" cellpadding="2" cellspacing="0" width="90%">
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<tbody>
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<tr valign="top">
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<td scope="row">
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<ol>
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<li>Age (years): _________ (if <1, Enter 0)</li>
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<li>
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<p>Gender</p>
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<p>__ 1 Male<br />
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__ 2 Female</p>
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</li>
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<li>
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<p>Race<em>(check all that apply)</em><br />
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</p>
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<p>__ 1 American Indian / Alaska Native<br />
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__ 2 Asian<br />
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__ 3 Native Hawaiian or Other Pacific Islander<br />
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__ 4 Black or African American<br />
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__ 5 White<br />
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__ 6 Unknown</p>
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</li>
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</ol>
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</td>
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<td>
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<ol start="4">
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<li>
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<p>Ethnicity</p>
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<p>__ 1 Hispanic or Latino<br />
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__ 2 Not Hispanic or Latino<br />
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__ 3 Unknown</p>
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</li>
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<li>
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<p>Insurance Status <em>(check all that apply)</em></p>
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<p>__ 1 Private or Managed Care<br />
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__ 2 Medicare<br />
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__ 3 Medicaid<br />
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__ 4 No Insurance / Self Pay<br />
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__ 5 Unknown</p>
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</li>
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</ol>
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</td>
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</tr>
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</tbody>
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</table>
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<h3>II. Visit Information — Reason for Visit:</h3>
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<table border="1" cellpadding="2" cellspacing="0" width="90%">
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<tbody>
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<tr valign="top">
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<td scope="row">
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<ol>
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<li>Visit Date <em>(MM/YYYY)</em>: ___ ___/20___ ___</li>
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<li>
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<p>Documented Risk Factors</p>
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<p><em>(check all that apply)</em><br />
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__ 1 Recent hospitalization <em>(within 1 month)</em><br />
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__ 2 Family member within <em>(last 6 months)</em><br />
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__ 3 Sport team: ____________________________<br />
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__ 4 History of MRSA: __________________<br />
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__ 5 Eczema<br />
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__ 6Other skin condition: ______________________<br />
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__ 7 Immunocompromized<br />
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<em>(Cancer, HIV, chronic oral steroid use, or<br />
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described as immunocompromized)</em><br />
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__ 8 Diabetes<br />
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__ 9 None</p>
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</li>
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<li>
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<p>Fever:</p>
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<p>a. History of fever: __ 1 Yes __ 0 No</p>
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<p> b. Visit temperature ______° __ 1 C __ 2 F</p>
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</li>
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<li>
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<p>Number of skin or soft tissue lesions: ______</p>
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<p><strong>a.</strong> Describe if no number given.</p>
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</li>
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<li>
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<p>Description of the <u>largest</u> lesion:<br />
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</p>
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<p>a. <strong>Location:</strong> _________________<br />
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<em>(face, neck, trunk, arm, hand, buttock, leg, foot, head, elsewhere)</em></p>
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</li>
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</ol>
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</td>
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<td>
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<ol start="5">
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<li>
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<p>Description of largest site continued:</p>
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<p>b. Size:<br />
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__ 1 < 1 cm<br />
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__ 2 1-5 cm<br />
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__ 3 > 5 cm<br />
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__ 4 Unknown/not documented in chart</p>
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<table border="1" cellpadding="2" cellspacing="0" width="90%">
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<tbody>
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<tr valign="top">
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<td> </td>
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<th scope="col">Yes</th>
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<th scope="col">No</th>
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<th scope="col">No Mention</th>
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</tr>
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<tr>
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<td scope="row">c. Red <em>(erythema)</em></td>
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<td>1</td>
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<td>0</td>
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<td>7</td>
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</tr>
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<tr>
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<td scope="row">d. Swollen <em>(edema)</em></td>
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<td>1</td>
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<td>0</td>
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<td>7</td>
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</tr>
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<tr>
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<td scope="row">e. Warm</td>
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<td>1</td>
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<td>0</td>
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<td>7</td>
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</tr>
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<tr>
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<td scope="row">f. Painful/Tender</td>
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<td>1</td>
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<td>0</td>
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<td>7</td>
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</tr>
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<tr>
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<td scope="row">g. Fluctuant, yellow or white center, central point or “head” <em>(induration)</em></td>
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<td>1</td>
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<td>0</td>
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<td>7</td>
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</tr>
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<tr>
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<td scope="row">h. Draining Pus <em>(discharge, purulent)</em></td>
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<td>1</td>
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<td>0</td>
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<td>7</td>
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</tr>
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</tbody>
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</table>
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</li>
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<li>
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<p>Incision and Drainage<em>(check all that apply)</em></p>
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<p>__ 1 Incision and Drainage<br />
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__ 2 Needle Aspiration<br />
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__ 3 Referred<br />
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__ 4 Manually Expressed<br />
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__ 5 Packed<br />
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__ 6 Not performed</p>
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</li>
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</ol>
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</td>
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</tr>
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</tbody>
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</table>
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<h3>III. Treatment and Follow-up</h3>
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<table border="1" cellpadding="2" cellspacing="0" width="90%">
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<tbody>
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<tr valign="top">
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<td scope="row">
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<ol>
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<li>
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<p>Culture —review the chart for:</p>
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<p>__ 1 Obtained<br />
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__ 0 Not Obtained</p>
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</li>
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<li>
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<p>If culture was obtained, which of the following was documented <em>(Check all that apply)</em></p>
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<p>__ 1 Final Culture Result:_________________<br />
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__ 2 Patient Notification<br />
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__ 3 New Prescription, specifiy:________________<br />
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__ 0 Not documented in chart</p>
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</li>
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<li>
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<p>Antibiotic Initially Prescribed: __ 1 Yes↓ __ 0 No</p>
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<p> 1a. If Yes, name(s): _________________________</p>
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</li>
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</ol>
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</td>
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<td>
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<ol start="4">
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<li>
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<p>Initial Antibiotic justification:</p>
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<p>__ 1 Empiric for suspected MRSA<br />
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__ 2 Empiric for non-MRSA or Streptococcus<br />
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__ 3 Other, specify: _______________________<br />
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__ 0 None</p>
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</li>
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<li>
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<p>Scheduled patient follow-up</p>
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<p>__ 1 PRN <em>(as needed)</em><br />
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__ 2 Return to clinic scheduled<br />
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__ 0 None</p>
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</li>
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<li>
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<p>Patient education <em>(Check all that apply)</em></p>
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<p>__ 1 Documented reasons to follow-up<br />
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__ 2 Patient hand-out<br />
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__ 3 Verbal teaching<br />
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__ 0 None</p>
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</li>
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</ol>
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</td>
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</tr>
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</tbody>
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</table>
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<h3>IV. Diagnoses and Billing Codes</h3>
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<table border="1" cellpadding="2" cellspacing="0" width="90%">
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<tbody>
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<tr valign="top">
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<td scope="row">
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<p>1. All ICD-9 Codes for the Visit:</p>
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<p>a. ___________</p>
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<p>b. ___________</p>
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<p>c. ___________</p>
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<p>d. ___________</p>
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<p>e. ___________</p>
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</td>
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<td>
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<p>2. All CPT Codes for the Visit:</p>
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<p>a. ___________</p>
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<p>b. ___________</p>
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<p>c. ___________</p>
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<p>d. ___________</p>
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<p>e. ___________</p>
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</td>
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</tr>
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</tbody>
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</table>
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<h3>V. Subsequent Office Care (next 14 days) and Patient Outcomes</h3>
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<table border="1" cellpadding="2" cellspacing="0" width="90%">
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<tbody>
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<tr valign="top">
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<td scope="row" width="50%">
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<p>A. Subsequent Office Care:</p>
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<ol>
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<li>Number of return office visits for the same infection(s): _______</li>
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<li>Any additional procedures in the office:</li>
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<li style=" list-style: none;">
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<table border="1" cellpadding="2" cellspacing="0" width="40%">
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<tbody>
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<tr valign="top">
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<td>If YES, complete section VI</td>
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</tr>
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</tbody>
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</table>
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<p> ← __ 1 Yes↓ __ 0 No</li>
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<li>Change in Antibiotic: __ 1 Yes __ 0 No 3a. If Yes, name(s):_________________________</li>
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<li>
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<p>Emergency department / urgent care visit:<br />
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</p>
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<p>__ 1 Yes __ 0 No</p>
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</li>
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<li>Hospitalization: __ 1 Yes __ 0 No</li>
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</ol>
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</td>
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<td>
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<p>B. Patient-reported Outcomes:</p>
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<ol>
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<li>Type of report: __ 1 Diary<br />
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__ 2 Telephone Survey<br />
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__ 0 None → <strong><em>(STOP, end of audit)</em></strong></li>
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<li>Number of days until resolution of fever: ____</li>
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<li>Number of days until resolution of infection: ____</li>
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<li>
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<p>Reported antibiotic change: __ 1 Yes↓ __ 0 No</p>
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<p> <strong>4a</strong>. If Yes, name(s):_________________________</p>
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</li>
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<li>Reported Emergency Department Visit: <br />
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__ 1 Yes __ 0 No</li>
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<li>Reported Hospitalization: __ 1 Yes __ 0 No</li>
|
|
</ol>
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
<h3>VI. Subsequent Visit Information (only answer the following sections if question V.A2. is “YES”)</h3>
|
|
<table border="1" cellpadding="0" cellspacing="0" width="90%">
|
|
<tbody>
|
|
<tr valign="top">
|
|
<td scope="row">
|
|
<ol>
|
|
<li>Visit Date <em>(MM/YYYY)</em>: ___ ___/20___ ___</li>
|
|
<li>
|
|
<p>Documented Risk Factors</p>
|
|
<p><em>(check all that apply)</em><br />
|
|
__ 1 Recent hospitalization <em>(within 1 month)</em><br />
|
|
__ 2 Family member within <em>(last 6 months)</em><br />
|
|
__ 3 Sport team: ____________________________<br />
|
|
__ 4 History of MRSA: __________________<br />
|
|
__ 5 Eczema<br />
|
|
__ 6Other skin condition: ______________________<br />
|
|
__ 7 Immunocompromized<br />
|
|
<em>(Cancer, HIV, chronic oral steroid use, or<br />
|
|
described as immunocompromized)</em><br />
|
|
__ 8 Diabetes<br />
|
|
__ 9 None</p>
|
|
</li>
|
|
<li>
|
|
<p>Fever: </p>
|
|
<p>a. History of fever: __ 1 Yes __ 0 No</p>
|
|
<p> b. Visit temperature ______° __ 1 C __ 2 F</p>
|
|
</li>
|
|
<li>Number of skin or soft tissue lesions: ______</li>
|
|
<li>
|
|
<p>Description of the <u>largest</u> lesion:</p>
|
|
<p>a. Location: _________________<br />
|
|
<em>(face, neck, trunk, arm, hand, buttock, leg, foot, head, elsewhere)</em></p>
|
|
</li>
|
|
</ol>
|
|
</td>
|
|
<td>
|
|
<ol start="5">
|
|
<li>
|
|
<p>Description of largest site continued:</p>
|
|
<p>b. Size:<br />
|
|
__ 1 < 1 cm<br />
|
|
__ 2 1-5 cm<br />
|
|
__ 3 > 5 cm <br />
|
|
__ 4 Unknown/not documented in chart</p>
|
|
<table border="1" cellpadding="2" cellspacing="0" width="80%">
|
|
<tbody>
|
|
<tr valign="top">
|
|
<td> </td>
|
|
<th scope="col">Yes</th>
|
|
<th scope="col">No</th>
|
|
<th scope="col">No Mention</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">c. Red <em>(erythema)</em></td>
|
|
<td>1</td>
|
|
<td>0</td>
|
|
<td>7</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">d. Swollen <em>(edema)</em></td>
|
|
<td>1</td>
|
|
<td>0</td>
|
|
<td>7</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">e. Warm</td>
|
|
<td>1</td>
|
|
<td>0</td>
|
|
<td>7</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">f. Painful/Tender</td>
|
|
<td>1</td>
|
|
<td>0</td>
|
|
<td>7</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">g. Fluctuant, yellow or white center, central point or “head” <em>(induration)</em></td>
|
|
<td>1</td>
|
|
<td>0</td>
|
|
<td>7</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">h. Draining Pus <em>(discharge, purulent)</em></td>
|
|
<td>1</td>
|
|
<td>0</td>
|
|
<td>7</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
</li>
|
|
<li>
|
|
<p>Incision and Drainage<em>(check all that apply)</em></p>
|
|
<p>__ 1 Incision and Drainage<br />
|
|
__ 2 Needle Aspiration<br />
|
|
__ 3 Referred<br />
|
|
__ 4 Manually Expressed<br />
|
|
__ 5 Packed<br />
|
|
__ 6 Not performed</p>
|
|
</li>
|
|
</ol>
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
<h3>VII. Subsequent Treatment and Follow-up</h3>
|
|
<table border="1" cellpadding="2" cellspacing="0" width="90%">
|
|
<tbody>
|
|
<tr valign="top">
|
|
<td scope="row" width="50%">
|
|
<ol>
|
|
<li>
|
|
<p>Culture —review the chart for:</p>
|
|
<p>__ 1 Obtained<br />
|
|
__ 0 Not Obtained</p>
|
|
</li>
|
|
<li>
|
|
<p>If culture was obtained, which of the following was documented <em>(Check all that apply)</em></p>
|
|
<p>__ 1 Final Culture Result:_________________<br />
|
|
__ 2 Patient Notification<br />
|
|
__ 3 New Prescription, specifiy:________________<br />
|
|
__ 0 Not documented in chart</p>
|
|
</li>
|
|
<li>Antibiotic Prescribed: __ 1 Yes __ 0 No 1a. If Yes, name(s):_________________________</li>
|
|
</ol>
|
|
</td>
|
|
<td>
|
|
<ol start="4">
|
|
<li>
|
|
<p>Antibiotic justification:</p>
|
|
<p>__ 1 Empiric for suspected MRSA<br />
|
|
__ 2 Empiric for non-MRSA or Streptococcus<br />
|
|
__ 3 Other, specify:_______________________<br />
|
|
__ 0 None</p>
|
|
</li>
|
|
<li>
|
|
<p>Scheduled patient follow-up</p>
|
|
<p>__ 1 PRN <em>(as needed)</em><br />
|
|
__ 2 Return to clinic scheduled<br />
|
|
__ 0 None</p>
|
|
</li>
|
|
<li>
|
|
<p>Patient education <em>(Check all that apply)</em></p>
|
|
<p>__ 1 Documented reasons to follow-up<br />
|
|
__ 2 Patient hand-out<br />
|
|
__ 3 Verbal teaching<br />
|
|
__ 0 None</p>
|
|
</li>
|
|
</ol>
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
<h3>VIII. Subsequent Diagnoses and Billing Codes</h3>
|
|
<table border="1" cellpadding="2" cellspacing="0" width="90%">
|
|
<tbody>
|
|
<tr valign="top">
|
|
<td scope="row">
|
|
<p>1. All ICD-9 Codes for the Visit:</p>
|
|
<p>a. ___________</p>
|
|
<p>b. ___________</p>
|
|
<p>c. ___________</p>
|
|
<p>d. ___________</p>
|
|
<p>e. ___________</p>
|
|
</td>
|
|
<td>
|
|
<p>2. All CPT Codes for the Visit:</p>
|
|
<p>a. ___________</p>
|
|
<p>b. ___________</p>
|
|
<p>c. ___________</p>
|
|
<p>d. ___________</p>
|
|
<p>e. ___________</p>
|
|
</td>
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
<p class="size2"><a href="/research/findings/final-reports/mrsa/nc_mrsa.html#contents">Return to Contents</a></p>
|
|
</div></div></div><div class="field field-name-field-last-reviewed field-type-datestamp field-label-hidden">
|
|
<div class="field-items">
|
|
<div class="field-item even">
|
|
Page last reviewed <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2014-10-01T00:00:00-04:00">October 2014</span> <br />Page originally created September 2012 </div>
|
|
</div>
|
|
</div>
|
|
<div id="block-ahrq-citation" class="block block-ahrq first odd">
|
|
|
|
|
|
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<div class="citation-flag"> </div> </div> <!--</div>--> <div class="footnote"> <p> The information on this page is archived and provided for reference purposes only.</p> </div> <p> </p> </div> </div></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div>
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