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23. Provide more in-depth medical history, especially when it relates to complete

or general assessments. This would reflect appropriate medical care. Particular

attention should be given to family history, social history, systemic review, and

significant past medical and surgical history.

24. Record all significant telephone calls in the charts including any telephone

advice given or action taken. Have charts pulled to go along with any phone call

messages and/or prescription refill requests in order to permit recording of any

details.

25. Recommend use of Saskatchewan Prenatal Forms for documenting risk scoring

and well-baby care.

26. Always measure and record the symphysis to fundal heights on the standard

antenatal record.

27. Indicate negative findings as well as positive information in the medical record.

28. When medical practice deviates from the norm, indicate on the medical record

reasons for such practice (i.e. non-compliant patient).

29. Consider documentation of date checks on pharmaceutical drug samples and

emergency crash kit drugs on a regular interval.

30. Incorporate use of clinical practice guideline flowsheets, especially for chronic

patients such as diabetics, hypertensives and coronary heart disease patients, to

ensure consistency and expediency in monitoring of risk factors.

31. Document allergies in visible/accessible areas on the chart.

32. Patients with depression should have appropriate history taken and advice given

should be consistently documented.

33. Ensure that patient identity is evident on all components of the chart.

34. Recommend doing in-office assessment of ongoing depression patients such as

the WHO-Five Well-Being Index. (Chart for initial assessment of depression)

35. Ensure that all chart entries are signed including co-signing those of residents.

III.

Office Facilities

36. Consider wheel-chair accessibility to the clinic and to facilities within the clinic.

37. Patients have complained that the walls between the consulting rooms are thin

and it is therefore easy to hear conversations in the next room. The clinic could

consider ways of dealing with this privacy issue such as background music.

38. Consider increasing the number of examining rooms in the clinic.

39. Consider arranging examination tables to face away from the door to ensure

patient privacy.

40. Establish a policy to ensure patient privacy when undressing in examination

rooms.

IV. Telephone System

41. It is recommended that an answering service be initiated to direct calls after

hours to the appropriate emergency on-call service and location

42. Consider increasing the number of incoming telephone lines

43. Consider having a private line for physician referral use

V.

Appointment System

44. Suggest development of a system to ensure patients in waiting room are not

neglected or missed.

45. Attempt to schedule more consistent general assessments.