Blue Cross and Blue Shield of Minnesota R e cog nizing Excellence 2008 Pediatric Asthma Management Audit Form Pay-for-performance program Last updated: 11/17/08 Blue Cross and Blue Shield of Minnesota is a licensee of the Blue Cross and Blue Shield Association 1 2008 Recognizing Excellence (RE) Medical Record Audit Form Numerator Tally PEDIATRIC ASTHMA MANAGEMENT RE criteria met? 1Yes 1No Date of Review: ____/____/___ Reviewer: _______________________ Specialty: Pediatrics Clinic site: ______________________ Clinician ID: ______________ Clinic System:____ _______________ BCBS Member ? 1Yes 1No Clinic Sample ID#: _________ Instructions :Review only the charts that meet the verified inclusion criteria referenced in the criteria summary table (diagnosis of asthma, between ages of 5-18 years, level of asthma severity documented, at least two years of clinic records and dates of service going back 2 years from Dec. 31, 2008). Missing information is considered a NO. Retain this audit tool with your Recognizing Excellence records for reference and validation. Verify Inclusion Criteria: 1. Is the patient between the ages of 5 and 18 as of Dec. 31, 2008 (Date of birth between Dec. 31, 1990 and Dec. 31, 2003)? 1 Yes 1 No If yes, proceed with next question. If no, do not ...
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