General Abstraction Guidelines When Completing Chart Review
Patients should be between the ages of 51 and 75 years of age and have been seen in your practice within the past 12 months. The data collection tool asks about care provided to each patient during the previous 12 months. A 50-year-old patient who should be screened for CRC may have been 49 years old at the time of the most recent previous visit, and it would not have been appropriate for screening to have been done at that time. Therefore, patients are included only if they are at least 51 years old, since they would have been 50 years old throughout the previous year. Patients at increased risk or high risk for CRC will be excluded. In general, screening recommendations for individuals at increased risk or high risk are more intensive. The frequency of screening/surveillance for increased risk or high risk will vary depending on the specific risk factor(s).
For you to count information as "present" the information must be recorded in at least one note for a previous visit. Information recorded during the current visit does not count toward this data collection.
When selecting "Other" on data collection tool, the reason should be documented in the patient's chart. Please see the following examples:
- Medical: Measure was not met due to an adverse effect, contraindication, drug interaction, allergy
- Patient: Measure was not met due to patient refusal, social, economic, religious reasons
- System: Measure was not met due to insurer/payer limitation, resources to perform the services not available (e.g., influenza vaccine shortage)