Alcohol Screening Audit Form 2010 - FINAL

Blue Cross and Blue Shield of Minnesota R e cognizing Excellence 2010 Alcohol Screening and Intervention Audit Form Pay-for-performance program Last Update: 8/2010 Blue Cross and Blue Shield of Minnesota is a licensee of the Blue Cross and Blue Shield Association Numerator TallySMRecognizing Excellence (RE) Medical Record Audit Form ALCOHOL SCREENING & INTERVENTION RE criteria met? 1Yes 1No Date of Review: ___/___/____ Reviewer: ________________________ Clinic Sample ID#: _________ Clinic System:____________________ Specialty: Behavioral Health Clinic Site: _______________________ BCBS Member ? 1Yes 1No Clinician ID (optional):______________________ Instructions: Audit only those records that meet the verified inclusion criteria referenced in the 2010 Inclusion/Exclusion Criteria Summary Table: patient age 18 or older with a behavioral health diagnostic evaluation. Answer each question with either yes or no. Retain this audit tool with your Recognizing Excellence records for reference and validation. Verify audit inclusion c riteria: A. Does the patient have a diagnostic evaluation documented in the record in 2010? 1 Yes 1 No If Yes, proceed with next question. If No, do not include this record in the denominator. Pull a new record from eligible population ...