Chart Audit for Diabetes HbA1c Poor Control Measure
Audit diabetes charts for the UDS HbA1c poor control measure and confirm the patient, lab result, and supporting documentation all line up. Use it to catch abstraction errors, missing evidence, and inconsistent notes before reporting.
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Overview
This chart audit template is built for reviewing diabetes records against the UDS poor control measure for patients with an HbA1c greater than 9.0% during the measurement period. It gives reviewers a structured way to confirm patient eligibility, verify the most recent qualifying HbA1c result, and check whether the chart contains enough clinical context to support the finding.
Use it when you need a defensible abstraction trail for quality reporting, internal QA, or second-level review. The template is especially helpful when results come from multiple sources, when outside labs must be traced back to a source document, or when the note, problem list, and lab tab do not match. It also helps reviewers document exclusions or exceptions clearly instead of leaving the rationale buried in free text.
Do not use this template as a general diabetes management checklist or as a substitute for clinical care planning. It is not meant for routine patient follow-up, medication titration, or broad chronic disease review. It is also not the right tool if your audit is focused on a different diabetes measure, a different HbA1c threshold, or a non-UDS reporting framework. The value of this template is precision: it keeps the review centered on the exact evidence needed to support a poor-control measure finding and the documentation quality around it.
Standards & compliance context
- This template supports quality reporting workflows commonly used in UDS-based diabetes measures, where documentation must support the reported HbA1c threshold and measurement period.
- The audit structure aligns with general quality management practices used in ISO 9001-style review processes by requiring traceable evidence, reviewer accountability, and documented outcomes.
- If your organization uses this review for clinical quality improvement, the documentation should remain consistent with internal policy and any applicable payer or health center reporting guidance.
- When outside laboratory results are involved, the source should be traceable in a way that supports auditability and reduces the risk of non-conformance in abstraction.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Audit Scope and Patient Eligibility
This section matters because it establishes whether the chart belongs in the measure before any lab review begins.
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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.
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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.
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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.
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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.
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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
This section matters because the measure hinges on the most recent qualifying HbA1c result and whether it can be traced to a source record.
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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.
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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.
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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.
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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.
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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
This section matters because a valid result still needs chart support, follow-up context, and internal consistency to stand up in review.
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Clinical note references the elevated HbA1c result
Check whether the provider note acknowledges the poor control result and documents clinical interpretation or follow-up.
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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.
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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.
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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
This section matters because it captures the final audit decision, the reason for any deficiency, and who completed the review.
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Audit outcome
Select the overall result of the chart audit.
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Primary deficiency category
Select the main reason the chart did not fully support the measure, if applicable.
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Corrective action or abstraction note
Document any needed correction, clarification request, or abstraction note for the chart review record.
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Reviewer name or identifier
Enter the auditor’s name, initials, or employee identifier.
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Review date
Record the date the audit was completed.
How to use this template
- 1. Enter the measurement period, reporting scope, and patient identifiers so the audit is tied to the exact chart and denominator rules being reviewed.
- 2. Confirm the diabetes diagnosis, age and encounter eligibility, and any exclusions or exceptions before you evaluate the lab result.
- 3. Locate the most recent HbA1c result during the measurement period and verify the date, value, units, and source document against the chart.
- 4. Review the clinical note, problem list, and related encounters to confirm the elevated result is acknowledged and that a follow-up plan is documented.
- 5. Record the audit outcome, deficiency category, and corrective action or abstraction note, then save the reviewer name and review date for traceability.
Best practices
- Verify the HbA1c against the source lab report or equivalent clinical record instead of relying on a copied value in a progress note.
- Check that the measurement period in the audit matches the reporting period exactly, especially when charts span calendar and program-year boundaries.
- Treat missing dates, missing units, or mismatched values as documentation deficiencies until the source record proves otherwise.
- Document exclusions and exceptions with enough detail that another reviewer can follow the decision without reopening the chart.
- Look for internal consistency across the problem list, encounter note, and lab tab before marking the chart complete.
- Capture the follow-up plan as written, including diabetes management actions, referrals, or patient outreach, when it is present in the record.
- Flag outside lab results carefully and note how the source was validated, since traceability is a common abstraction failure point.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What does this chart audit template verify?
This template verifies the documentation needed to support the UDS diabetes poor control measure for patients with an HbA1c greater than 9.0% during the measurement period. It checks eligibility, the most recent qualifying lab result, and whether the clinical record supports the finding. It also captures audit outcomes and corrective notes so reviewers can close the loop. Use it when you need a repeatable abstraction record, not just a one-time chart review.
Who should use this template?
Quality staff, clinical auditors, care coordinators, and practice managers can use it to review charts before submission or during internal QA. It is also useful for clinicians who want to verify that the chart supports the measure before final sign-off. The template is structured so one reviewer can complete it consistently, but it also works well for second-level review. If your organization separates abstraction and validation, this template supports both roles.
How often should this audit be run?
Most teams use it during the measurement period as charts are identified, then again near closeout to catch missing documentation or conflicting entries. It can also be run on a monthly or quarterly cadence for internal monitoring. The right frequency depends on your reporting workflow and how often charts are updated after the encounter. If your measure review is retrospective, use it after the measurement period but before final submission.
What records should be reviewed for this audit?
Review the problem list, encounter notes, lab results, and any documented exclusions or exceptions that affect denominator inclusion. The template also expects the source document for the HbA1c result, such as a lab report or equivalent clinical record. If the chart references outside testing, verify that the result is traceable and dated within the measurement period. The goal is to confirm that the audit trail is complete, not to rely on a single note.
How does this template relate to UDS and quality reporting requirements?
It is designed to support documentation review for a UDS diabetes quality measure, where the patient has an HbA1c greater than 9.0% during the measurement period. The template helps align chart evidence with common quality reporting expectations by checking eligibility, result validity, and note consistency. It does not replace your organization’s reporting rules or payer guidance. Use it alongside your internal abstraction policy and any applicable quality program instructions.
What are the most common mistakes this audit catches?
Common issues include a missing or outdated HbA1c date, a result that is not traceable to a source lab record, and a chart note that mentions diabetes without supporting the measure period. Reviewers also find inconsistent values between the lab tab and the progress note, or missing documentation for exclusions. Another frequent problem is a follow-up plan that exists clinically but is not documented clearly enough for abstraction. This template helps surface those gaps early.
Can this template be customized for local workflows?
Yes. You can add fields for reviewer initials, site location, payer program, or a second-review sign-off if your workflow requires it. Many teams also add a checkbox for outside lab verification or a free-text field for abstraction rationale. If your organization uses a different measurement period or internal denominator rules, those can be reflected in the audit scope section. The structure is flexible while still keeping the core evidence checks intact.
How is this different from an ad-hoc chart review?
An ad-hoc review often answers only one question, such as whether the HbA1c was above 9.0%. This template turns the review into a repeatable audit by capturing eligibility, source evidence, documentation quality, and closeout actions in one place. That makes it easier to compare reviewers, defend abstraction decisions, and track recurring deficiencies. It also reduces the chance that a chart is marked complete without a traceable source record.
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