Outpatient Audit Form

Level

Self-limited or Minor

Stable Chronic Illness(= at treatment goal)

Acute, Uncomplicated Illness or Injury

Chronic w/Exacerbation/progression/side effects

Undiagnosed New Problem w/ Uncertain Prognosis

Acute Illness w/ Systemic Symptoms

Chronic w/ Severe Exacerbation/progression/side effects

Acute or Chronic Illness/injury threat to life/bodily function

Level

Minimal risk of recurrences morbidity from additional diagnostic testing or treatment

Low risk of mordbidity from additional diagnostic testing or treatment

Over-the-counter drugs

Minor surgery w/o riskfactors

Low recurrences

Physical/Occupational Therapy

IV fluids without additives

Other

Moderate risk of morbidity from additional diagnostic testing or treatment

RX Minor surgery w/o risk factors

Elective major surgery w/o risk factors

Diagnosis/treatment significantly limited by social determinants of health

Moderate risk of recurrence

IV with additives (Fe infusion)

Other

High risk of mordbidity from additional diagnostic testing or treatment

Drug Therapy intensive monitoring for toxicity

Major surgery w/ risk factors

Hospitalization

De-escalate care/poor prognosis (example hospice)

High risk of recurrence

Other

Level

Category 1: Tests, documents, or independent historian(s)

1 2 3+ Review of prior external note(s) from each unique source (not your own notes)

1 2 3+ Review of the result(s) of each unique test (Not previously used in prior visit(s))

1 2 3+ Ordering of each unique test

Assesment requiring an independent historian(s)

Category 2: Independent interpretation of tests

Independent interpretation of a test performed by another physician/other qualified healthcare proffessional (not separately reported)

Category 3: Disscussion of management or test interpretation

Disscussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not seperately reported)

0 - 1

Category 1: 2 Or Independent Historian(s)

Category 1: 3 Or Category 2:

Or Category 3:

Must Meet 2 of 3 Below:
Category1: 3 Category 2: 1 Category 3: 1

Problems

Risk

Low Morbidity Examples

Moderate Morbidity Examples

High Morbidity Examples

Data

Category Criteria Examples