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118

TOC

There is ample evidence that lifestyle and health maintenance issues are

addressed. There were numerous records of telephone advice given to

patients.

Chronic disease charts contained copious evidence of consistent follow-

up. Chronic disease management records were in place for diabetic

patients.

Asthma records contained good documentation of diagnostic criteria

and follow-up management. Some contained consultants’ reports that

included pulmonary function reports. Dr. ABC’s clinic has a spirometer

and one of the staff has been recently trained in its use. The charts

did not contain evidence of the use of the an objective measure of

pulmonary function such as the 30 Second Asthma Test.

Cardiovascular Risk Management charts all contained extensive records

of careful diagnosis and follow-up. Lipid values were carefully monitored

as was blood glucose. ECG records, echocardiograms, and consultant

notes were usually present. Dr. ABC’s notes demonstrated she counsels

patients on the need for weight control and exercise. Exercise tolerance

reports and letters from the Live Well program were present. Patient

responses confirm she counsels on smoking cessation. Some of the

records included BMI calculations.

Depression charting showed good detail regarding symptoms, diagnosis

and management. The treatment plans were easy to follow. Sufficient

detail was included of counselling sessions to understand the course

of treatment. Suicide risk assessment or risk of harm to others was

not recorded. An assessment tool such as the PHQ9 would help give

structure to the charting.

Diabetes records contained ample diagnostic and treatment data. The

charts reviewed contained chronic disease management charting. These

were generally well completed. Records of visits to community resources

such as the diabetic educators were included. Home glucose monitoring

reports were included. Hemoglobin A1C, renal function data, and lipid

values were recorded. Ophthalmology consultations were present.

Hypertension records contained good detail, including home blood

pressure monitoring results. Blood glucose, renal function, and lipids

were monitored consistently.

Pediatric records all contained fully completed Rourke and Growth

charts.

Suggestions:

Review procedures for creating and maintaining current medication lists

to avoid duplication.

Consider extending the use of chronic disease management forms

Action Taken

By Physician

Assessed: