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HIV/AIDS Care and Outcomes Chart Audit for Quality Assurance and Quality Improvement Contents
Preface and Quick-Start Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Chart Audits for Quality Assessment & Improvement Activities . . . . . . . . . . 3. Sample Size Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Chart Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Completing the Audit Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Item Description (Definitions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Quick Start Directions:
1. Review the audit form, definitions and criteria with all chart reviewers (pg 7-10) 2. Select in random fashion the appropriate number of charts to review (pg 5-6). Instructions for the
IHS HIV/AIDS Care and Outcomes Chart Audit

The instructions that follow describe a standardized method for assessing HIV/AIDS care and the health status of HIV/AIDS patients at your partnership facility. Using a uniform process and standardized definitions provides consistency as you monitor patient care patterns over time. It allows valid comparison of your facility with other facilities. The indicators in this audit were selected by a group of HIV/AIDS experts from the Saratov/Engels – Bemidji AIHA partnership. and are consistent with World Health Organization HIV/AIDS guidelines. Instructions for sample size calculations, selecting charts for the audit, and standard definitions for each item are given on the next few pages. Additional assistance, if necessary, can be obtained from your AIHA partners and Quality Improvement consultants.
For any facility to provide quality HIV/AIDS, on-going self-assessment and improvement activities are necessary. A number of techniques or methods to pursue improvement may be employed. A central feature of each of these systems is some form of an improvement cycle: With respect to HIV/AIDS, the basic questions to be answered are straightforward: "Are we doing those things that we agreed were important for maximizing the health of our patients with HIV/AIDS?" and "Are there ways that we could do better?" Getting accurate and reliable answers is more complex, of course, but this HIV/AIDS audit process is designed to make it The Saratov/Engels – Bemidji AIHA HIV/AIDS partnership recommends an annual medical record review to monitor care patterns and changes over time at your facility. You should select in a random manner a large enough sample of medical records so that you can be reasonably certain that observed changes are significant and not just due to chance (see sections 5 and 6). All of the indicators on the audit form, which reflect compliance with the WHO 3X5 Guidelines, should be completed as outlined in section 7. The staff at your facility may be asked to participate in the audit process. While this process may seem tedious at first, many providers have found that participating in the chart audit provides a review of the standards of care for HIV/AIDS and identifies trends in HIV/AIDS care at their facility. Through the audit, the providers often have a better idea of what changes they can make to improve the outcome for people who suffer from this potentially devastating Once the chart audit is complete, the data may be entered into an electronic database, from which you can easily print a summary report. The report shows the percentage of charts having documentation of compliance with each of the indicators. Your AIHA partnership can assist you in obtaining reports and comparison data. In addition, your AIHA partnership can assist you in identifying program strengths and deficiencies. Facilities are encouraged to review the recommendations in a team setting, establish priorities together, and develop an action plan with a timetable for re-evaluation. Table 1 - Sample Size Calculations (see next page for explanation)
Sample size needed to be 90% or 95% certain that the rate you find is within 10% or within 5% of the true
Population ╒═══════ 90% Certainty ══════╕ ╒═══════ 95% Certainty
10% Within
5% Within
10% Within
The number of charts you will need to select depends on the number of patients with HIV/AIDS who receive their HIV/AIDS care at your clinic. These patients should be listed in a registry. Table 1 on the previous page outlines the minimum number of charts you will need to audit to be reasonably sure (90% confident) that a 10% difference noted from a previous or subsequent audit is a real change and not just due to chance. If, for example, your facility has 1000 active patients with HIV/AIDS, you will need to audit a total of 63 charts (see Table 1). The HIV/AIDS register will often include people who are not considered active patients of the clinic and thus do not need to be audited. These charts should be identified early in the audit process and excluded. Table 2 outlines the charts which are to be included and excluded.
Table 2 Patients to Include and Exclude in the Chart Audit

Include patients who:

• Attend regular clinics or HIV/AIDS clinics. • Refuse care or have special motivational problems (e.g., alcoholism, Injection Drug • Are not attending clinic, but you do not know if they have moved or have found another source of care.
Exclude patients who:
• Have not had at least one visit during the past 12 months. • Live in a jail, and receive care in jail and not at your clinic. • You are unable to contact, defined as 3 tries in 12 months (should be documented in the chart). • Have died. Keep in mind that unless your HIV/AIDS register is frequently updated, up to 10% of the people in the HIV/AIDS registry may not qualify to be included in the audit. To make sure you have an adequate sample at the end of the audit, increase the chart sample by at least 10%. In the
example of 63 charts used above, this would mean an additional 6 charts, or a total of 69, would 4. CHART SELECTION
The systematic random sampling technique will provide the best representative sample for audit.
This is done in the following fashion: Suppose you need to select 69 charts from a registry list of
1000 patients. First, divide 1000 by 69, which yields the number 14.4. You now know that you
must select one chart out of fourteen. However, don't automatically start with the first person.
Use any method of random chance to determine which one of the first 14 people on the list should
be selected. Use your imagination . Number 14 pieces of paper with 1 through 14 and have
someone draw one, or simply ask someone to pick a number between 1 and 14. Then use that
number to select your first name for chart audit. Proceed through the entire list, selecting every
14th person on the list. Please note that it is important to track down the charts which are
missing from Medical Records as these are likely to belong to patients who have been
seen recently and have high compliance with the Standards of Care.


Using the instructions that follow, review the medical record to see if each of the indicators are
satisfied. If you cannot find a result in the chart, then for the purposes of the audit, apply the old
"If it is not documented, it did not happen."
Finally, please remember that all medical records are confidential documents and need to
be handled accordingly.

CLINIC NAME: The name of the clinic/facility being audited
AUDIT DATE: Enter the day of the audit, day/month/year
Clinic Type: check off the type of clinic or facility: AIDS Center or other.
NUMBER OF PATIETS WITH HIV/AIDS IN CLINIC: Enter the number of living patients with the
diagnosis of HIV or AIDS who have received care at least once in your clinic in the past 2 years. If
you do not know the exact number, please make your best estimate of the number of patients
with HIV or AIDS served by the clinic.
REVIEWER: Enter the initials of the person conducting the audit.
CHART NUMBER: Enter the medical chart number or identifier. This is helpful to check for
DATE OF BIRTH: Enter day/month/year.
SEX: Self-explanatory

Select all that apply:
…2 Heterosexual, includes commercial sex workers and other heterosexual transmission …3 Transfusions, patients who have had blood product transfusions, including for hemophilia. …4 Perinatal, maternal to child transmission …5 Other, includes men who have sex with men, bisexual individuals HIV/AIDS STAGE:
Check the current stage of HIV disease according to the Russian Health Ministry classification
Stage Criteria Documented
Has the provider documented the criteria for the stage?
DATE of HIV/AIDS Diagnosis: Enter day/month/year that the diagnosis of HIV infection was
confirmed by laboratory testing. If only the year of diagnosis is stated, enter "07/01" of that year. If only the month and year are stated, enter the 15th of that month. Leave blank if date is CURRENT ART THERAPY
Review the chart for the current anti-retroviral drugs that are prescribed. Check all of the
medications that apply.
Select all that apply

(Nucleoside Reverse Transcriptase Inhibitors)
(Non-Nucleoside Reverse Transcriptase Inhibitors)


…1 Fusion Inhibitor
…2 Other - list abbreviation(s) of other medication(s) not listed above Date current regimen started: Enter the day/month/year the current treatment regimen was
prescribed. If a new medication was added to an existing regimen, enter the date the new
medication was added. If one of multiple medications prescribed was changed, enter the date of
this change.
Not On Any Therapy: Check this box of the patient is not prescribed any antiretroviral therapy.
Then, check the box indicating the reason why it is not prescribed.
…1 not indicated –for example, Asymptomatic HIV infection, undetectable viral loads
…2 contra-indicated – for example, documented no adherence and at high risk for developing
resistance, failed treatment and end-stage disease, severe adverse drug reactions
…3 refused – patient has be offered but refused therapy.
…4 Other – For example, patient can not afford cost of medication or medication is not available
Enter the value of the most recent CD4 Count and the date it was obtained. Then enter the next most recent CD4 (or ALC) Count and the date it was obtained. Enter the value of the most recent viral load and the date it was obtained. Then enter the next most recent viral load and the date it was obtained. COEXISTANT INFECTION SCREENING

Tuberculosis Status
Was the patient screened for tuberculosis in past year? This could be done by chest radiograph,
sputum culture, or PPD administration. If the patient screened positive, is there documentation of
appropriate treatment? Enter yes if treatment is documented, no if it is documented that the
patient was not treated, refused if treatment is offered but patient refusal is documented, or
unknown if treatment status is not documented.

Hepatitis C Screening in the past year
Was the patient tested for hepatitis C in the past year? If yes, enter the result.

Syphilis Screening in the past year
Was the patient tested for syphilis in the past year?

Prophylaxis for Opportunistic Infections
Pnemocystis Prophylaxis
Indicate if patient is currently receiving prophylactic therapy for pneumocytsis carnii
Indicate if patient is currently receiving prophylactic therapy for cryptococcosis
Indicate if patient is currently receiving prophylactic therapy for mycobacteriosis
Patient Education
Is there documentation that the following educational topics have been addressed with the patient
in the past year:
Medication Adherence – If the patient is on anti-retroviral medication, is there documentation
that the patient was counseled on the importance of medication adherence at each visit during
the past year?

Transmission Risk
– Is there documentation that the patient was counseled on how to reduce
risk of HIV transmission in the past 6 months. Examples include counseling on not sharing needles, (for injection drug users) and condom use.
Assessments and Referrals
Psycho-social Assessment –
Has the patient had an assessment of mental health social
barriers to care in the past year.
Alcohol Assessment – Has alcohol use been assessed in the past year? If a problem has been
identified, has the patient been referred to treatment in the past 6 months?

Drug Abuse Assessment

Has drug abuse been assessed in the past year? If a problem has been identified, has the patient been referred to treatment in the past 6 months? Pregnancy Status
Was pregnancy status assessed in women of childbearing age 14-50 years? This could be done
by either documentation of last menstrual period or pregnancy test.
Clinic utilization past year

Enter the date of the last visit: day/month/year
Enter the number of documented visits past year for HIV/AIDS related care Has the patient been seen by a HIV Specialist in past year? Has the patient been seen by a Case Manager in care in past year? ASSESSMENT OF HIV/AIDS CARE IN ADULTS
CLINIC NAME: __________________________________ Clinic Type: …1 AIDS Center …2 Other________________ Number of patients with HIV in Clinic: _______ REVIEWER’S INITIALS: ______ CHART NUMBER : _________ PATIENT EDUCATION
Opportunistic Infection Prophylaxis
… Not On Any Therapy



The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan. The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. PLEASE NOTE: The symbol * nex

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