Chart Audit for Controlling High Blood Pressure Measure

Chart audit to verify that hypertensive patients ages 18 to 85 have a documented most recent blood pressure reading and that control is below 140/90 mmHg, with follow-up documentation when not controlled.

Audit Setup and Patient Eligibility

• Patient age is between 18 and 85 years on the measurement date
• Patient has a diagnosis of hypertension or is included in the hypertension denominator
• Measurement period and chart review date are documented
• Chart source reviewed

Most Recent Blood Pressure Documentation

• Most recent blood pressure reading is documented in the chart
• Date of the most recent blood pressure reading is documented
• Most recent systolic blood pressure
• Most recent diastolic blood pressure

Blood Pressure Control Assessment

• Most recent blood pressure is below 140/90 mmHg
• If blood pressure is not controlled, escalation or follow-up plan is documented
• Most recent blood pressure reading appears to be the lowest documented reading when multiple readings are present
• Blood pressure measurement context is documented

Follow-Up, Documentation Quality, and Closeout

• If the reading is elevated, a repeat BP, counseling, medication adjustment, or follow-up plan is documented
• Blood pressure documentation is legible, complete, and attributable to a specific encounter
• Any missing or conflicting blood pressure values were reconciled in the audit note
• Auditor comments and corrective actions documented