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Run: Chart Audit for Early Entry into Prenatal Care Measure

Use this chart audit to verify whether prenatal patients entered care in the first trimester and whether the chart supports the UDS early prenatal care measu...

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Audit Scope and Patient Eligibility

Patient record is within the prenatal care audit population critical (required)

Confirm the chart belongs to a patient receiving prenatal care and is included in the audit sample for the UDS measure.

Yes No N/A

Pregnancy episode and estimated due date are documented critical (required)

Verify the chart contains a current pregnancy episode and an estimated due date or equivalent dating information.

Yes No N/A

First prenatal encounter date is identifiable critical (required)

The first prenatal care visit date should be clearly documented in the chart or abstraction source.

Yes No N/A

Relevant source documents reviewed

Select all chart sources used to verify prenatal entry timing.

Note (optional)

First Trimester Entry Verification

Gestational age at first prenatal visit is documented critical (required)

Verify the chart states gestational age in weeks and days, or enough dating information to calculate it.

Yes No N/A

First prenatal visit occurred in the first trimester critical (required)

Confirm the first prenatal encounter occurred at less than 14 weeks 0 days gestation, per the measure definition used by the organization.

Yes No N/A

Date of last menstrual period or ultrasound dating supports timing critical (required)

Verify the chart contains LMP, ultrasound dating, or another accepted dating method supporting the gestational age calculation.

Yes No N/A

First trimester entry can be confirmed without ambiguity

The documentation should clearly support first trimester entry and not rely on inference from incomplete notes.

Documentation Quality and Supporting Evidence

Initial prenatal assessment includes pregnancy dating details

Verify the initial assessment documents dating details such as LMP, ultrasound, or estimated gestational age.

Yes No N/A

Prenatal care start date is consistent across chart sources

Check that the documented first prenatal visit date is consistent across notes, intake forms, and supporting records.

Yes No N/A

Any late entry or conflicting dating is explained

If there are conflicting dates or evidence suggesting later entry, the chart includes a clear explanation or reconciliation.

Yes No N/A

Documentation quality rating

Rate the overall quality of documentation supporting the measure.

Exclusions, Exceptions, and Final Determination

Measure exclusion applies

Indicate whether an allowable exclusion applies based on the chart record or organizational measure rules.

Note (optional)

Final measure determination critical (required)

Select the final audit outcome based on the chart evidence reviewed.

Note (optional)

Corrective action needed

Document whether follow-up is needed for missing or unclear prenatal dating documentation.

Yes No N/A

Audit notes

Enter any additional findings, clarification, or chart abstraction notes.

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