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Audit Scope and Sample Verification

At least 30 consecutively seen patients are included in the audit sample critical (required)

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 critical (required)

Verify the sample was selected from consecutively seen patients without cherry-picking.

Yes No N/A

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 critical (required)

The care plan identifies the patient's current problems, diagnoses, or care needs.

Yes No N/A

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 critical (required)

Verify the care plan includes current medications or a medication summary relevant to the patient's plan of care.

Yes No N/A

Medication-related concerns or adherence issues are addressed when applicable

If medication barriers, side effects, or adherence concerns are present, the plan addresses them.

Yes No N/A

Goals, Preferences, and Self-Management Support

Patient-centered goals are documented critical (required)

The care plan includes one or more measurable or meaningful goals tied to the patient's needs.

Yes No N/A

Goals are measurable or time-bound

Rate whether the goals are specific enough to support follow-up and progress tracking.

Patient preferences are documented critical (required)

Verify the plan reflects patient preferences, priorities, or stated choices.

Yes No N/A

Self-management support is documented critical (required)

The care plan includes education, coaching, action steps, or other self-management support.

Yes No N/A

Expected outcomes are stated critical (required)

The care plan identifies the expected result or outcome of the plan of care.

Yes No N/A

Barriers, Solutions, and Follow-Up

Barriers to care are identified critical (required)

The care plan documents barriers such as transportation, cost, language, health literacy, or access issues when present.

Yes No N/A

Solutions or interventions address identified barriers critical (required)

The plan includes actions to reduce or overcome documented barriers.

Yes No N/A

Follow-up visit date or timeframe is documented critical (required)

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.

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Run: PCMH Care Plan Audit Template

Audit Scope and Sample Verification

Problem List and Clinical Needs

Goals, Preferences, and Self-Management Support

Barriers, Solutions, and Follow-Up

Documentation Quality and Audit Findings

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