Form #12 Form #12 Chart audits

Patient Study ID Number____________

CRC Screening Chart Audit Form

Patient Study ID No______________

Male______ Female_________

Preferred Language: ____English ____Spanish ____Other ____Missing

Marital Status: ____Single ____Married ____Divorced, Separated or Widowed ____Missing

Ethnicity: ____Hispanic or Latino _____Non-Hispanic or Non-Latino ____Missing

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

Practice ID___________________

Auditor_______________________________________ Audit Date _____/_____/_____

MM DD YY

Instructions: Document information on colorectal cancer screening test performance from the medical chart.

• If no testing in a category performed, check no result.

• If multiple tests were performed in one category, provide information on most recent test.

• If the information comes from a source other than the medical chart, indicate the source.

Section A. Stool Test (ST)- Since < date

A-1. ST Result ___Yes ___No

A-2. Most recent ST ST Result Date ____/____/____

MM DD YY

ST Result ____ Normal

____ Abnormal(specify)_____________________

ST Reason ____ Screening Test

____ Diagnostic Test

____ Unknown

A-3. Source used other than Medical Chart: ____No ____Yes (specify)________________

Section B. Flexible Sigmoidoscopy (FSig)- Since < date

B-1. FSig Result ____Yes ____No

B-2. Most recent FSig FSig Result Date ____/____/____

MM DD YY

FSig Result ___ Normal

___ Abnormal(specify)___________________

FSig Reason ___ Screening Test

___ Diagnostic Test

___ Unknown

B-3. Source used other than Medical Chart: ____No ____Yes (specify)________________

Section C. Barium Enema X-Ray (BE)- Since < date

C-1. BE Result ____Yes ____No

C-2. Most Recent BE BE Result Date ____/____/____

MM DD YY

BE Result ___ Normal

___ Abnormal(specify)___________________

BE Reason ___ Screening Test

___ Diagnostic Test

___ Unknown

C-3. Source used other than Medical Chart: ____No ____Yes (specify)______________

Section D. Colonoscopy (Cx) - Since < date

D-1. Cx Result ____Yes ____No

D-2. Most Recent Cx Cx Result Date ____/____/____

MM DD YY

Cx Result ___ Normal

___ Abnormal(specify)___________________

Cx Reason ___ Screening Test

___ Diagnostic Test

___ Unknown

D-3. Information found in (Check all that apply) ____ Flow Sheet ____ Consults

____ Progress Note ____ Labs

____Other, specify: ________________

D-4. Source used other than Medical Chart: ____No ____Yes (specify)______________

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