Chart Audit for Breast Cancer Screening Measure

Chart review audit verifying that women ages 50–74 had a mammogram within 27 months prior to the end of the measurement period, per the UDS Breast Cancer Screening measure (aligned with CMS0125v14 / NCQA BCS-E).

Audit Setup & Patient Identification

• Auditor Name
  Full name of the staff member conducting this chart audit.
• Audit Date
  Date on which this chart audit is being performed.
• Measurement Period End Date
  Enter the last day of the measurement period (typically December 31 of the measurement year). The 27-month lookback window is calculated from this date.
• Patient Record / Chart ID
  Enter the de-identified patient record number or chart ID. Do NOT enter patient name or full date of birth in this field.
• Site / Clinic Location
  Name or code of the clinic site where the patient receives care.
• Auditor has reviewed the measure specification (CMS0125v14 / UDS BCS) prior to beginning this audit
  Confirm familiarity with the measure before proceeding. Reference: https://ecqi.healthit.gov/ecqm/ec/2026/cms0125v14

Patient Eligibility Verification

• Patient sex recorded as female in the medical record
  The measure applies to patients with a recorded sex of female. Verify this is documented in the demographic record.
• Patient age at end of measurement period
  Enter the patient's age as of the last day of the measurement period. Eligible range is 50–74 years (inclusive), per CMS0125v14 and NCQA BCS-E.
• Patient was continuously enrolled / had at least one visit during the measurement period
  Confirm the patient had at least one qualifying visit or enrollment during the measurement period as required by the measure denominator criteria.
• Exclusion: Bilateral mastectomy documented in the medical record
  If a history of bilateral mastectomy is documented, the patient is excluded from the denominator. Check problem list, surgical history, and procedure notes.
• Exclusion reason (if applicable)
  If the patient is excluded from the measure denominator, select the applicable exclusion reason.

Mammogram Documentation Review

• Mammogram result or report is present in the medical record
  Confirm that at least one mammogram report, result, or documented order/referral with confirmed completion exists in the chart.
• Date of most recent mammogram on record
  Enter the date of the most recent mammogram documented in the chart. This date must fall within the 27-month lookback window.
• Mammogram date falls within the 27-month lookback window
  Confirm the documented mammogram date is within 27 months prior to the measurement period end date, per CMS0125v14 and UDS BCS measure specifications.
• Source of mammogram documentation
  Select the source where the mammogram evidence was found in the chart.
• Mammogram result / finding category documented
  Is the mammogram result or BI-RADS category (or equivalent) documented in the record?
• Additional notes on mammogram documentation
  Record any clarifying details about the mammogram documentation, discrepancies found, or follow-up actions needed.

Measure Compliance Determination

• Overall measure status for this chart
  Select the final compliance status for this patient record based on the audit findings.
• Gap in care identified (patient due or overdue for mammogram)
  If the numerator is not met and the patient remains eligible, flag this chart for outreach or care gap closure.
• Recommended follow-up action
  Select the recommended next step based on audit findings.
• Auditor comments and findings summary
  Summarize key findings, discrepancies, or actions taken during this chart review.

Auditor Sign-Off

• All sections of this chart audit have been completed accurately and to the best of my knowledge
  Auditor attestation of completeness and accuracy.
• Auditor Signature
  Electronic signature of the staff member who completed this chart audit.