Chart Audit for prevalence of
drug and disease indicators
Patient sex:
M
Patient age:
________
Date of last visit (yy.mm.dd):
___________________
Physician name:
______________________________________
IMPACT Project 2006
F
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or DOB (yy.mm.dd) _____________
Chart #: ______
Site #:________
Date:___/___/___
D
M
Y
Screening Form:
Review the patient chart for each of
Chart #: ______
Site #:________
Date:___/___/___
D
M
Y
the following criteria.
TO BE COMPLETED BY IMPACT
Consider referral to IMPACT
Not included as part of case finding for IMPACT
Not to be considered as part of case finding for IMPACT:
Less than one visit to the family physician in the last 12 months [ ] Yes [ ] No [ ] Don’t Know
More than 20 visits to the family physician in the last 12 months [ ] Yes [ ] No [ ] Don’t Know
Awaiting placement to a nursing home or long-term care…………[ ] Yes [ ] No [ ] Don’t Know
Alcoholism………………………………………………………………[ ] Yes [ ] No [ ] Don’t Know
Palliative care patient……………………………….…………………[ ] Yes [ ] No [ ] Don’t Know
Family physician only sees as a home visit ……………………….. [ ] Yes [ ] No [ ] Don’t Know
(i.e. patient cannot come to the clinic)
If you chose Yes for any of the above criteria, DO NOT collect any further information on this form.
Considered for case finding strategy: referral to IMPACT
Patient has to be 65 years of age or over AND meet either
¾ 2 criteria in Section 1
¾
OR
1 criterion each in Section 1 and Section 2
Section 1: Vascular and Symptom Based Criteria
1. Elevated blood pressure- one reading>155/95mmHg or 140/90mmHg in diabetics
2. Elevated - HbA1c >0.075 (7.5%)
3. Elevated LDL-C >3.4mmol/L (F) or >2.6mmol/L (M)
4a. Diagnosis of Hypertension and NO blood pressure readings in the past 12 months OR
b. Diagnosis of Diabetes and NO HbA1c readings in the last 12 months OR
c. Diagnosis of Hyperlipidemia and NO LDL readings in the past 12 months
5. Diagnosis of Osteoarthritis or Rheumatoid Arthritis
6. Using narcotics (codeine, morphine or other as per list)
7. Diagnosis of hypertension, diagnosis of diabetes and not using an ACEI
8. Diagnosis of hypertension, elevated blood pressure and using an NSAID
9. Diagnosis of hyperlipidemia, elevated LDL and not using a lipid lowering agent
10. Diagnosis of hypertension, high blood pressure and not using a potassium wasting diuretic
Section 2: Drug-Based Criteria
1. using an NSAID with NO BUN/Creatinine levels measured in past 12 months OR BUN/creat is elevated
2. using a potassium wasting diuretic with NO potassium levels measured in the past 12 months OR low potassium
3. using ACE-I and NO BUN/Creatinine levels measured in the past 12 months OR BUN/creat is elevated
4. using ACE-I and NO potassium levels measured in the past 12 months OR elevated potassium
5. using phenytoin and drug level is elevated
6. using theophylline and drug level is elevated
7. using lithium and drug level is elevated
8. using digoxin and the drug level is elevated
9. using Estrogen / Hormone Replacement Therapy (ERT)
10. using more than 8 medications
Other
11. More than 2 hospitalizations in past 12 months
IMPACT Project 2006
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Screening Form:
Review the patient chart for each of the following
criteria. At least two of the boxes should be checked
for each criteria.
Chart #: ______
Site #:________
Date:__/__/__
D M Y
Section 1: Vascular and Symptom Based Criteria
1. Record HbA1c readings measured in the past 12 months: (if > 3 in past 12 months record 3 most recent readings)
Check ([) if there are no readings in the past 12 months, and proceed to question 2.
Date (DD/MM/YY)
HbA1c reading
Elevated (check box if >0.075)
Begin with most recent
2. Record blood pressure (BP) readings in the past 12 months: (if > 4 readings in past 12 months record 4 most recent)
Check ([) if there are no readings in the past 12 months, and proceed to question 3.
Date (DD/MM/YY)
Systolic (mmHg)
Diastolic (mmHg)
Elevated (>155/95mmHg or 140/90mmHg in diabetics)
Begin with most recent
3. Record LDL (cholesterol) readings in the past 12 months and complete the following table:
Check if there are no readings in the past 12 months, and proceed to question 4.
LDL reading
Elevated (female and LDL >3.4 OR
Date (DD/MM/YY)
Begin with most recent
male and LDL >2.6)
4. Patient has osteoarthritis OR rheumatoid arthritis……………………..[ ] Yes
[ ]No
5. Patient using narcotics (codeine OR morphine)……………………….[ ] Yes
[ ]No
Section 2: Drug Based Criteria
6. Patient using a NSAID…………………………………… [ ] Yes [ ] No
(BUN/creatinine measured within 12 months)………….. [ ] Yes [ ] No
(Last BUN/Creatinine measurement within 12 mos. is elevated) [ ] Yes [ ] No
[ ]Don’t Know
[ ]Don’t Know
[ ]Don’t Know
7. Patient using a potassium wasting diuretic………………. [ ] Yes [ ] No
(potassium measured within 12 months)………………….. [ ] Yes [ ] No
(Last potassium measurement within 12 mos. is low)……….…..[ ] Yes [ ] No
[ ]Don’t Know
[ ]Don’t Know
[ ]Don’t Know
8. Patient using Phenytoin …………………………………… [ ] Yes [ ] No
(drug level is elevated)…………………………………….. [ ] Yes [ ] No
[ ]Don’t Know
[ ]Don’t Know
9. Patient using Digoxin………………………………………. [ ] Yes [ ] No
(drug level is elevated)……………………………………. [ ] Yes [ ] No
[ ]Don’t Know
[ ]Don’t Know
10. Patient using Theophylline……………………………….. [ ] Yes [ ] No
(drug level is elevated)……………………………………. [ ] Yes [ ] No
[ ]Don’t Know
[ ]Don’t Know
11. Using ACE I………………………………………………… [
(BUN/creatinine measured within 12 months)…………… [
(Last BUN/Creatinine measurement within 12 mos. is elevated)[
(potassium level measured within 12 months)……….……[
(Last potassium measurement within 12 mos. is elevated)…….[
[
[
[
[
[
] Yes
] Yes
] Yes
] Yes
] Yes
[
[
[
[
[
] No
] No
] No
] No
] No
]Don’t Know
]Don’t Know
]Don’t Know
]Don’t Know
]Don’t Know
12. Using Lithium………………………………………………. [ ] Yes [ ] No
(TSH measured in past 12 months)……………………… [ ] Yes [ ] No
(drug level is elevated)……………………………………. [ ] Yes [ ] No
[ ]Don’t Know
[ ]Don’t Know
[ ]Don’t Know
13. On Estrogen Replacement Therapy…………………….. [ ] Yes [ ] No
[ ]Don’t Know
14. Is the patient taking more than 8 medications?………… [ ] Yes [ ] No
[ ]Don’t Know
Other
15. Was patient hospitalized more than 2 times in past 12 months?…………… [ ] Yes [ ] No
IMPACT Project 2006
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[ ]Don’t Know
ADDITIONAL INFORMATION
Diagnoses
Does patient have any of the following conditions? (based on written words in chart):
Diabetes
[ ] Yes [ ] No
hypertension/high blood pressure
[ ] Yes [ ] No
hyperlipidemia/ hypercholesteremia/ high cholesterol
[ ] Yes [ ] No
[ ] Don’t know
[ ] Don’t know
[ ] Don’t know
If “NO” checked for all 3 conditions do not complete the drug lists below
Is the patient using any of the following diuretics: (√ check only if using drug)
[ ] chlorthalidone (hygroton, novo-thalidone, apo-chlorthalidone)
[ ] furosemide (lasix, novo-semide, apo-furosemide, furoside, uritol)
[ ] hydrochlorothiazide (hydrodiuril, novo-hydrazide, apo-hydro 25 (or 50) hydrochlorothiazide)
[ ] hydrochlorothiazide & spironolactone (aldactazide-25 (or 50), novo-spirozine-25 (or 50)
[ ] hydrochlorothiazide & triamterene (apo-triazide, novo-triamzide, nu-triazide, dyazide,
hydrochlorothiazide & triamterene)
[ ] indapamide (lozide, gen-indapamide, apo- indapamide)
[ ] metolazone (zaroxolyn)
[ ] spironolactone (aldactone, novo-spiroton)
[ ] triameterene (dyrenium)
[ ] hydrochlorothiazide & losartan (hyzaar)
Using any of the following ACE inhibitors: (√ check only if using drug)
[ ] benazepril (lotensin)
[ ] captopril (capoten, syn-captopril, apo-capto, nu-capto, novo-captopril, gen-captopril)
[ ] cilazapril (inhibace)
[ ]enalapril (vasotec)
[ ] fosinopril sodium (monopril)
[ ] lisinopril (prinivil, zestril)
[ ] lisinopril & hydrochlorothiazide (zestoretic, prinzide)
[ ] perindopril erbumine (coversyl)
[ ] quinapril (accupril)
[ ] ramipril (altace)
Using any of the following ARBs (√ check only if using drug)
[ ] irbesartan (avapro)
[ ] candasartan (atacard)
[ ] losartan (cozaar, hyzaar)
[ ] telmisartan (micardis)
[ ] valsartan (diovan)
Using any of the following antilipemic drugs: (√ check only if using drug)
[ ] atorvastatin (lipitor)
[ ] bezafibrate (bezalip)
[ ] cholestyramine Resin (questran, novo-cholamine light, PMS-cholestyramine,
syn-cholestyramine)
[ ] clofibrate (atromid-S, novo-fibrate)
[ ] colestipol HCL (colestid)
[ ] fenofibrate (lipidil, apo-fenofibrate, nu-fenofibrate, lipidil micro)
[ ] fluvastatin sodium (lescol)
[ ] gemfibrozil (mevacor)
[ ] pravastatin sodium (pravachol)
[ ] rosuvastatin (crestor)
[ ] simvistatin (zocor)
IMPACT Project 2006
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DRUG CLASSES
Narcotics include:
- codeine preparations (codeine, codeine phosphate, Tylenol #1 or 2 or 3 or 4, emtec, empracet, atasol, exdol,
novo-gesic, AC&C, 282, 292)
- fentanyl (duragesic)
- hyromorphone hcl (dilaudid, hydromorphone)
- meperidine hcl (demerol)
- morphine (m.o.s., morphitec, m-eslon, ms contin, oramorph sr, morphine sulphate, statex, MS-IR)
- oxycodone (percocet, percodan, oxycocet, oxycodan, endocet, endodan
NSAIDs include:
- rofecoxib (vioxx)
- celecoxib (celebrex)
- meloxicam (mobicox)
- diclofenac sodium (voltaren, novo-diclofenac, apo-diclo, nu-diclo, diclofenac sodium, arthrotec)
- diflunisal (dolobid, apo-diflunisal, novo-diflunisal)
- fenoprofen (nalfon)
- floctafenine (idarac)
- flurbiprofen (froben, ansaid,flurbiprofen, apo-flurbiprofen, nu-flurbiprofen, novo- flurprofen)
- ibuprofen (apo-ibuprofen, novo-profen, motrin)
- indomethacin (indocid, novo-methacin, apo-indomethacin, nu-indo, indotec, novo-methacin)
- ketoprofen (rhodis, apo-keto, orudis, PMS-ketoprofen, novo-keto)
- naproxen (naprosyn, naxen, apo-naproxen, novo-naproxen, nu-naprox)
- piroxicam (feldene, apo-piroxicam, novo-piroxicam, nu-pirox, kenral-piroxicam (or Rho-, Gen-, PMS)
- sulindac (clinoril, novo-sundac, apo-sulin, nu-sulindac)
- tiaprofenic acid (albert-tiafen, surga m, apo-tiaprofenic, novo-tiaprofenic)
- tolmetin (tolectin, novo-tolmetin)
Potassium Wasting include:
- furosemide (lasix, novo-semide, apo-furosemide, uritol)
- hydrochlorothiazide (hydrodiuril, novo-hydrazide, apo-hydro)
- indapamide (lozide, gen-indapamide, apo-indapamide)
- metolazone (zaroxolyn)
Cardiovascular drugs include:
- digoxin (lanoxin)
Lithium includes:
- lithium (carbolith, lithane, lithizine)
Estrogen Replacement Therapy (ERT) products:
- estradiol-17 (climara, estalis, estalis-sequi, estrace, estracomb, Estraderm, estradot, estring, estrogel,
oesclim, rhoxal-estradiol derm, vagiferm)
- estradiol benzoate (climacteron)
- estradiol valerate (delestrogen)
- conjugated estrogens (C.E.S, Premarin tablets)
- conjugated estrogens + medroxyprogesterone acetate (premplus)
IMPACT Project 2006
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