Breast Cancer Screening Audit Tool
Manual Data Collection Sheet
Date of review
Patient ID
Auditor
Inclusion criterion:
Female patient age between 52 – 69 as of 12/31/04 Y N
Female patient seen at least 3 times in the past 3 years Y N
If no to either of the above, this file is ineligible for this audit
Exclusion criterion
Female patient who has had a bilateral mastectomy Y N
If yes, this file is ineligible for this audit
Mammography verification (check one):
Patient received mammogram, results in chart
Patient reported mammogram completed, no results in chart
No documentation of mammogram
If patient did not receive mammogram (check one):
Patient declined
Mammogram ordered, not completed
No discussion of mammography (by documentation or patient report)
Other, please specify______
Please check if applies:
Attempted to reach by phone
Successfully reached patient
Turn in all of these sheets with the summary, please.