PCMH Care Plan Audit Template

Audit at least 30 consecutively seen patient care plans to verify required PCMH elements are documented, including problems, medications, goals, patient preferences, barriers and solutions, self-management support, expected outcomes, and a follow-up visit date.

Audit Scope and Sample Verification

• At least 30 consecutively seen patients are included in the audit sample
  Record the number of patient charts reviewed. The sample should include at least 30 consecutively seen patients.
• Audit period and clinic/site are identified
  Document the date range, location, and service line or provider panel included in the audit.
• Consecutive selection method is documented
  Verify the sample was selected from consecutively seen patients without cherry-picking.
• Chart identifiers are recorded in a de-identified format
  List chart identifiers or audit references without exposing unnecessary patient identifiers.

Problem List and Clinical Needs

• Active problems or diagnoses are documented
  The care plan identifies the patient's current problems, diagnoses, or care needs.
• Problems are specific and clinically meaningful
  Rate whether the documented problems are specific enough to guide care planning and follow-up.
• Medication list is included in the care plan
  Verify the care plan includes current medications or a medication summary relevant to the patient's plan of care.
• Medication-related concerns or adherence issues are addressed when applicable
  If medication barriers, side effects, or adherence concerns are present, the plan addresses them.

Goals, Preferences, and Self-Management Support

• Patient-centered goals are documented
  The care plan includes one or more measurable or meaningful goals tied to the patient's needs.
• Goals are measurable or time-bound
  Rate whether the goals are specific enough to support follow-up and progress tracking.
• Patient preferences are documented
  Verify the plan reflects patient preferences, priorities, or stated choices.
• Self-management support is documented
  The care plan includes education, coaching, action steps, or other self-management support.
• Expected outcomes are stated
  The care plan identifies the expected result or outcome of the plan of care.

Barriers, Solutions, and Follow-Up

• Barriers to care are identified
  The care plan documents barriers such as transportation, cost, language, health literacy, or access issues when present.
• Solutions or interventions address identified barriers
  The plan includes actions to reduce or overcome documented barriers.
• Follow-up visit date or timeframe is documented
  Record the next follow-up visit date/time or a clearly documented timeframe for follow-up.
• Follow-up plan is clinically appropriate
  Rate whether the follow-up timing and plan match the patient's needs and documented goals.

Documentation Quality and Audit Findings

• Care plan documentation is complete and internally consistent
  Rate the overall completeness and consistency of the care plan documentation across the reviewed sample.
• Non-conformances or deficiencies are summarized
  Summarize recurring documentation gaps, missing elements, or other deficiencies identified during the audit.
• Corrective actions are identified for failed items
  Document the corrective action plan, owner, and target completion date for any deficiencies found.
• Audit reviewer name and completion date are recorded
  Enter the name or role of the reviewer and the audit completion date.