Templates › Inspections › SEO page

Run: Chart Audit for BMI Screening and Follow-Up Measure

Chart audit template for BMI screening and follow-up documentation in adult encounters. Use it to verify BMI was recorded, classified correctly, and paired w...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Audit Setup and Patient Eligibility

Auditor Name

Full name of the clinician or quality staff conducting this chart audit.

Audit Date

Date this chart audit is being performed.

Patient Medical Record Number (MRN)

De-identified or masked MRN for tracking purposes. Do not enter full name or SSN.

Patient Age at Time of Encounter critical (required)

Patient must be 18 years or older to be included in this measure per CMS69v14.

Eligible Encounter Type Documented critical (required)

Confirm the chart includes an eligible encounter type (e.g., office visit, preventive visit, annual wellness visit) during the measurement period as defined by CMS69v14.

Patient Exclusion Criteria Checked

Verify whether any denominator exclusions apply (e.g., pregnancy, palliative care, hospice enrollment). If an exclusion applies, note it and stop the audit.

BMI Measurement Documentation

BMI Value Documented in Chart critical (required)

A numeric BMI value (kg/m²) is recorded in the chart during the eligible encounter or within the measurement period. This is a critical numerator requirement per CMS69v14.

Yes No N/A

Recorded BMI Value critical (required)

Enter the BMI value as documented in the chart (kg/m²). Normal range per CDC/NIH: 18.5–24.9 kg/m².

BMI Measurement Date Documented

The date the BMI was measured or calculated is recorded in the chart.

Yes No N/A

Height and Weight Values Recorded

Both height (in/cm) and weight (lbs/kg) are documented in the chart, supporting the BMI calculation.

Yes No N/A

BMI Classification and Follow-Up Trigger

BMI Classification critical (required)

Classify the documented BMI per standard CDC/NIH categories. A follow-up plan is required for Underweight (<18.5), Overweight (25.0–29.9), or Obese (≥30.0).

Follow-Up Plan Required Based on BMI Classification

Based on the BMI classification above, is a follow-up plan required? Answer Yes if BMI is outside the normal range (18.5–24.9 kg/m²).

Yes No N/A

Medical or Behavioral Reason Documented for Abnormal BMI

If BMI is outside normal range, is there a documented clinical reason or contributing condition (e.g., eating disorder, chronic illness, medication effect)?

Yes No N/A

Follow-Up Plan Documentation

Follow-Up Plan Documented When BMI is Abnormal critical (required)

A follow-up plan is present in the chart for patients with BMI outside normal range. If BMI was normal, mark N/A. This is a critical numerator requirement per CMS69v14.

Type of Follow-Up Plan Documented

Select all follow-up plan components documented in the chart. Multiple selections allowed.

Follow-Up Plan is Specific and Actionable

The documented follow-up plan includes specific interventions, referrals, or instructions — not a generic note. Vague entries such as 'discussed diet' without specifics do not meet the measure intent.

Yes No N/A

Follow-Up Plan Documented Within the Same Encounter or Measurement Period

The follow-up plan was documented at the same visit or within the measurement period as required by CMS69v14.

Yes No N/A

Documentation Quality and Compliance

Ordering / Documenting Provider Identified in Chart

The provider responsible for the BMI screening and follow-up plan is clearly identified in the chart note.

Yes No N/A

Overall Documentation Completeness Rating

Rate the overall completeness of BMI screening and follow-up documentation in this chart.

Corrective Action or Re-Education Required

Based on this audit, does the provider or care team require corrective action, documentation coaching, or re-education on MIPS Measure #128 requirements?

Yes No N/A

Note (optional)

Auditor Notes and Observations

Document any additional findings, deficiencies, or observations not captured above. Include specific chart note references where applicable.

Auditor Signature

Auditor signature confirming accuracy of this chart review.

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free