1 Middle School Audit Form (Version 2.2 7/2008) Table I – Annual Risk Assessment and Physical Examination Student – unique ID number Gender Age in Marker: Had risk assessment in Marker: Had physical exam in past 12 months years past 12 months 0=no exam 0=male 0= no risk assessment 1= exam 1=female 1=risk assessment (There must be 20 rows in this column for every chart) Total 0= 0= 0= 1= 1= 1= Measurement 1= 0-25% of charts with both markers documented 2=26-50% of charts with both markers documented 3=51-75% of charts with both markers documented 4= 71-95% of charts with both markers documented 5= >95% of charts with both markers documented 2 Table II: Asthma Student- Unique ID Number Gender Age in Marker: Asthma Marker: Number of visits with asthma identified as well 0=male Years Classification controlled (*)/Number of visits since asthma plan in place 1=female 0=asthma not classified 1=asthma classified Total 0= 0= 1= 1= Measurement 1= 0-40% of charts have asthma classified 2=41-60% of charts have asthma classified 3=>60-100% have asthma classified and 20-50% of visits identify asthma as well controlled 4= >60-100% have asthma classified and 51-75% of visits identify asthma as well controlled 5= >60-100% have asthma classified and >75% of visits identify asthma as well controlled (*) ...
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