Chart Audit for Diabetes HbA1c Poor Control Measure

Chart audit template to verify documentation supporting the UDS diabetes quality measure for patients with HbA1c greater than 9.0% during the measurement period.

Audit Scope and Patient Eligibility

• Patient has a documented diagnosis of diabetes during the measurement period
  Confirm the chart contains evidence of diabetes on the problem list, encounter diagnosis, medication history, or other clinical documentation relevant to the measure.
• Measurement period is clearly identified and matches the audit scope
  Verify the chart review is limited to the correct reporting period and the documentation reviewed falls within that period.
• Patient is included in the denominator based on age and encounter criteria
  Confirm the chart supports inclusion criteria used for the UDS diabetes measure, including applicable age and qualifying encounter requirements.
• Any documented exclusions or exceptions are present and supported
  Check whether the chart contains valid exclusion documentation, if applicable, and whether the rationale is clear and traceable.
• Source documents reviewed are listed in the audit notes
  Identify which chart sources were used for abstraction, such as lab results, problem list, encounter notes, and scanned documents.

HbA1c Result Verification

• Most recent HbA1c result during the measurement period is documented
  Verify the chart contains the latest HbA1c value within the measurement period, not merely a historical result.
• Most recent HbA1c value is greater than 9.0%
  Record the most recent HbA1c result and confirm it meets the poor control threshold used for the measure.
• HbA1c test date is documented and within the measurement period
  Confirm the lab date is present and the result was obtained during the reporting period.
• HbA1c result source is traceable to a lab report or equivalent clinical record
  Verify the value can be traced to a source document such as an in-house lab result, external lab interface, or scanned report.
• Result units and formatting are consistent with the source document
  Confirm the recorded value uses percent (%) and matches the source lab report without transcription errors.

Documentation Quality and Clinical Context

• Clinical note references the elevated HbA1c result
  Check whether the provider note acknowledges the poor control result and documents clinical interpretation or follow-up.
• Follow-up plan for diabetes management is documented
  Verify there is a plan addressing diabetes control, such as medication adjustment, counseling, repeat testing, or referral.
• Relevant comorbidities or clinical factors affecting glycemic control are documented
  Confirm the chart includes context that may explain or inform management of poor control, when applicable.
• Documentation is internally consistent across notes, labs, and problem list
  Check for discrepancies between the lab result, diagnosis list, and provider documentation.

Audit Findings and Closeout

• Audit outcome
  Select the overall result of the chart audit.
• Primary deficiency category
  Select the main reason the chart did not fully support the measure, if applicable.
• Corrective action or abstraction note
  Document any needed correction, clarification request, or abstraction note for the chart review record.
• Reviewer name or identifier
  Enter the auditor's name, initials, or employee identifier.
• Review date
  Record the date the audit was completed.