(Clinic Name) Chart Review: Screening for Overweight and Obesity
1. Audit Period _____________________________________
2. Patient ID: ______________________ 3. Clinic ID: ______________________ 4. Assigned PCP ID: ______________________
Patient Demographics
5. Date of birth:______________________ 6. Gender: ___ Male ___ Female
Medical History
7. Which of the following conditions can you confirm for this patient? (Check all that apply.)
| ___ Arthritis—circle: Osteo or Other | ___ Hypertension |
| ___ Asthma | ___ Overweight |
| ___ Cancer—specify type(s):  | ___ Obesity |
| ___ Coronary Artery Disease (CAD) | ___ Pregnancy |
| ___ Congestive Heart Failure | ___ Pulmonary Embolism |
| ___ Chronic Back Pain | ___ Sleep Apnea |
| ___ Depression | ___ Stroke |
| ___ Diabetes—circle: Type 1 or Type 2 | ___ Substance Abuse |
| ___ Dyslipidemia—circle: hyper or hypo | ___ None of the conditions listed |
| ___ Gallbladder disease | ___ Other weight related—specify: ______________________________________ |
Weight Management During Audit Period
8. Total Visits During Audit Period: ____________________________________________________________________________
9. Weight Management Tracking
| Visit # | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
|---|---|---|---|---|---|---|---|
| Date (mm/dd/yy) | ___/____/___ | ___/____/___ | ___/____/___ | ___/____/___ | ___/____/___ | ___/____/___ | ___/____/___ |
| Height (in inches) | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 |
| Weight (in lbs) | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 |
| BMI | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 |
| Other weight measures? | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 |
| Weight discussed? (Circle 1, 2, 3, 4) | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 |
| Diet discussed? (Circle 1, 2, 3, 4) | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 |
| Exercise discussed? (Circle 1, 2, 3, 4) | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 | 1 2 3 4 |
| Weight Management Referral? | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 | Y1 ____ N2 |
| Other relevant information |
Instructions for Filling Out the Chart Audit
- Audit period. Check pre-intervention or post-intervention as appropriate to the audit period you are using.
- Patient ID. This should be a unique id number that cannot be linked back to an individual patient. Choose the number and enter.
- Clinic ID. This should be a unique id number. Choose the number and enter.
- Assigned PCP ID. This is the PCP that is designated as the primary clinician for that patient. This should be a unique id number. Choose the number and enter.
- Date of birth. Enter patient DOB as mm/dd/yy.
- Gender. Check male or female.
- Medical history. Check all conditions that the patient has listed in their medical record. For certain conditions document where additional information is required:
- Arthritis—circle osteo or other.
- Cancer—specify type(s).
- Diabetes—circle Type 1 or type 2.
- Dyslipidemia—circle: hyper or hypo (note hyperlipidemia, hypercholesterolemia are types of dyslipidemia).
- Other weight related—specify.
Weight Management Tracking During Audit Period
- Total visits. Write the total number of visits during the audit period here. If there are more than 7 visits during the audit period add a new sheet and continue to track.
- Weight Management Tracking
- Height, Weight, BMI. If these are obtained, circle "Y" for yes and record the value using the units designated (height = inches; weight = lbs.). If these are not obtained circle "N" for no in the appropriate cell.
- Other weight measures: Some clinics may use alternate means to record weight status such as Body Fat Percentage (BFP), Abdominal Circumference (AC), or Growth Curves (GC). If this is the case, circle "Y" for yes and indicate type. If not circle "N" for no.
- Weight, diet, exercise discussed. Please circle the appropriate response as follows:
- 1 = Documented present, current. Chart indicates that the topic was discussed.
- 2 = Documented not present. Chart indicates that the topic was NOT discussed.
- 3 = Not documented/unknown. Chart makes no indication if topic was or was NOT discussed.
- 4 = Documented present, historical. Chart indicates that topic may have been discussed years ago (i.e., appears in history).
- Weight management referral. If yes, circle "Y" and indicate the name of the organization or individual to which the patient was referred. If no circle "N".
- Other relevant information. Document anything noteworthy or unclear here, or indicate where this is documented.
