TALK – Early Monthly Audit Tool TALK – Early Monthly Audit Tool Practice Name * Date * 1 - How many adolescents do you have in your practice? 11 through 14 year olds: * 15 through 17 year olds: * 18 through 21 year olds: * 2 - How many adolescents attended a well child visit in the past 13 months? (Use the appropriate ICD-10 and/or CPT code noted below.) 11 through 14 year olds: * 15 through 17 year olds: * 18 through 21 year olds: * 3 - During the past month, how many clinic visits were for an adolescent well child visit? (Use the appropriate code noted below.) 11 through 14 year olds: * 15 through 17 year olds: * 18 through 21 year olds: * 4 - During the past month, how many adolescent clinic visits were for sports clearance physical? (ICD10=Z02.5) 11 through 14 year olds: * 15 through 17 year olds: * 18 through 21 year olds: * 5 - From the patient list in measure 4, how many of those adolescents attended a well visit in the past 13 months? (Use the appropriate code noted below.) 11 through 14 year olds: * 15 through 17 year olds: * 18 through 21 year olds: * 6 - During the past month, how many adolescent clinic visits were for a non-well visit, non-sports clearance? (Based on any CPT or ICD-10 code that is not a WCV or sports clearance.) 11 through 14 year olds: * 15 through 17 year olds: * 18 through 21 year olds: * 7 - From the patient list in measure 6, how many of those adolescents attended a well visit in the past 13 months? (Use the appropriate code below.) 11 through 14 year olds: * 15 through 17 year olds: * 18 through 21 year olds: * 8 - From the practice registry: How many adolescents/families were provided recall/reminders about well visits? 11 through 14 year olds: * 15 through 17 year olds: * 18 through 21 year olds: * 9 - From the practice registry: How many adolescents/families that were provided recall/reminders about well visits, scheduled their well visit? 11 through 14 year olds: * 15 through 17 year olds: * 18 through 21 year olds: * If you are human, leave this field blank.
