All patients visiting the practice, regardless of age
Sample Selection
Records should be selected in a random way designed to represent a cross section of patients of all age and gender groups seen by a clinician at a clinic in the last month for any reason. There are various ways to accomplish this:
- Use the appointment list or lists (if various specialties and departments are present) from a recent day or days and take every name (if a small list) or every 5th or 10th name (if a large list) until at least 50 charts have been found. Note that it is important to include documentation of the recent visit, so if this information is dictated, choose a date that will assure that the dictated record is back in the chart.
- Select charts randomly from those that are being refiled from a recent visit (if they contain documentation of the visit) until at least 50 charts have been found. These should be selected in a way that allows inclusion of all types of patients being seen.
- If charts are refiled before visit documentation is included, you may randomly select from the dictated notes as they are being prepared to be filed in the charts.
Data Collection
Use the Tobacco Use Status Audit Form (found in the original measure documentation) and enter the patient's name or ID# and age in the appropriate column for every chart audited until at least 50 have been entered. In order to know exactly how to record each chart audited, use the following definitions:
Current Non-User = a label or mark anywhere on the chart (or on general forms like a problem list) or on the most recent visit progress note that shows that the patient has been asked at least once and reported not using tobacco. If the patient is a child or adolescent, a similar identification should be used to show that the child is not exposed to smoke from a parent or guardian (i.e., if the child is breathing the smoke of others regularly, she or he is a smoker).
Current User = information at the most recent visit progress note that shows that a user was asked about use at that visit. This task will be simplified if the clinic uses some type of label or general mark on the chart that shows that the patient was a user once. However, for this category it is necessary to document at the most recent visit just what the tobacco use is. If there is a general label but no notation at the most recent visit, the chart should be included in the unknown category.
Unknown = either no label or mark on the chart, or a label as a user with no documentation at the recent visit as to the current use status.
Analysis
Add up all the charts that are in either the User or the Non-User columns for the numerator. Then add to this number all of the Unknown charts to obtain the denominator. Divide and multiply by 100 in order to obtain the % measure.
The suggested schedule is to audit monthly until 75% identification has been achieved. Then it is acceptable to measure only every 3 months until 85% has been achieved, at which time yearly measures will be satisfactory. However, whenever a measure falls below the 85% or 75% level, the reporting frequency should revert to quarterly or monthly as appropriate until the rate has been raised above the cutoff point described.
