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