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Alcohol Screening Audit Form 2010 - FINAL

De
3 pages
Blue Cross and Blue Shield of Minnesota R e cognizing Excellence 2010 Alcohol Screening and Intervention Audit Form Pay-for-performance program Last Update: 8/2010 Blue Cross and Blue Shield of Minnesota is a licensee of the Blue Cross and Blue Shield Association Numerator TallySMRecognizing Excellence (RE) Medical Record Audit Form ALCOHOL SCREENING & INTERVENTION RE criteria met? 1Yes 1No Date of Review: ___/___/____ Reviewer: ________________________ Clinic Sample ID#: _________ Clinic System:____________________ Specialty: Behavioral Health Clinic Site: _______________________ BCBS Member ? 1Yes 1No Clinician ID (optional):______________________ Instructions: Audit only those records that meet the verified inclusion criteria referenced in the 2010 Inclusion/Exclusion Criteria Summary Table: patient age 18 or older with a behavioral health diagnostic evaluation. Answer each question with either yes or no. Retain this audit tool with your Recognizing Excellence records for reference and validation. Verify audit inclusion c riteria: A. Does the patient have a diagnostic evaluation documented in the record in 2010? 1 Yes 1 No If Yes, proceed with next question. If No, do not include this record in the denominator. Pull a new record from eligible population ...
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Blue Cross and Blue Shield of Minnesota
























R e cognizing Excellence

2010







Alcohol Screening and
Intervention


Audit Form

Pay-for-performance program

Last Update: 8/2010























Blue Cross and Blue Shield of Minnesota
is a licensee of the Blue Cross and Blue Shield
Association
Numerator TallySMRecognizing Excellence (RE) Medical Record Audit Form
ALCOHOL SCREENING & INTERVENTION RE criteria met? 1Yes 1No

Date of Review: ___/___/____ Reviewer: ________________________
Clinic Sample ID#: _________ Clinic System:____________________
Specialty: Behavioral Health Clinic Site: _______________________ BCBS Member ? 1Yes 1No
Clinician ID (optional):______________________
Instructions:
Audit only those records that meet the verified inclusion criteria referenced in the 2010 Inclusion/Exclusion Criteria
Summary Table: patient age 18 or older with a behavioral health diagnostic evaluation. Answer each question with
either yes or no.

Retain this audit tool with your Recognizing Excellence records for reference and validation.

Verify audit inclusion c riteria:
A. Does the patient have a diagnostic evaluation documented in the record in 2010?
1 Yes
1 No

If Yes, proceed with next question.
If No, do not include this record in the denominator. Pull a new record from eligible population identified.
B. Is the patient 18 or older as of the date of the behavioral health diagnostic evaluation (Birth date on or before December 31,
1991)?
1 Yes
1 No

If Yes, include this record in the denominator and proceed with the next question.
If No, do not include this record in the denominator. Pull a new record from eligible population identified.




Assess optimal Alcohol Screening and Intervention through the following measure:

1. Did the clinician ask the patient if they had any alcohol use in the year prior to the visit, i.e. at least one alcoholic drink on one
occasion?
1 Yes
1 No

If Yes, proceed with next question.
If No, do not include this record in the numerator. This record is included in the denominator; the audit of this record is
complete.

2. When asked, does the patient report any alcohol use in the year prior to the visit, i.e. at least one alcoholic drink on one
occasion?
1 Yes
1 No
If Yes, proceed with next question.
If No, include this record in the numerator. This record is included in the denominator; the audit of this record is complete.

3. If the patient reported any alcohol use in the year prior to the visit, is there documentation of the results of administration of a
standardized alcohol screening questionnaire? (A standardized alcohol screening questionnaire is a set of questions
designed and validated to detect possible problem drinking and/or an alcohol use disorder. Standardized questionnaires
have published cut scores.)
1 Yes (Check standardized questionnaire administered.)
ο National Institute on Alcohol Abuse & Alcoholism (NIAAA) Heavy Drinking Days Question
ο AUDIT
ο-C
ο CAGE
ο CAGEAID
ο Other standardized screening questionnaire. List name ___________________________
1 No, standardized screening questionnaire results not found.

If Yes, proceed with the next question.
If No, do not include this record in the numerator. This record is included in the denominator; the audit of this record is
complete.
Continue to next page



4. Does the score of the standardized screening questionnaire meet or exceed the cut score for that particular
questionnaire? Please note, if the questionnaire has lifetime questions (eg CAGE, CAGEAID), please answer “yes”
only if there is evidence that the patient has abused alcohol in the past year.
1 Yes
1 No

If Yes, proceed with next question.
If No, include this record in the numerator. This record is included in the denominator; the audit of this record is
complete.

5. Is there documentation of a recommendation to the patient to reduce alcohol use or abstain? Or, if the patient reports
efforts to reduce use or abstain from use at the time of the visit, please check “Yes” below.
1 Yes
1 No

If Yes, include this record in the numerator. This record is included in the denominator; the audit of this record is
complete.
If No, do not include this record in the numerator. This record is included in the denominator; the audit of this record is
complete.



Recognizing Excellence Numerator Checklist
Count in the numerator:
• If Question 2 is No, count the record in the numerator for Alcohol Screening & Intervention. ( Check
the Yes box in the Numerator Tally on the front of the form.)
• If Questions 1, 2 & 3 are Yes and Question 4 is No, count the record in the numerator for Alcohol
Screening & Intervention. (Check the Yes box in the Numerator Tally on the front of the form.)
• If Questions 1, 2, 3, 4 & 5 are Yes, count the record in the numerator for Alcohol Screening &
Intervention. (Check the Yes box in the Numerator Tally on the front of the form.)

Do not count in the numerator:

• If Questions 1, 3 or 5 is No, this record cannot be counted in the numerator. This record is included
in the denominator (Check the No box in the Numerator Tally on the front of the form.)



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