There is ample evidence that lifestyle and health maintenance issues are
addressed. There were numerous records of telephone advice given to
Chronic disease charts contained copious evidence of consistent follow-
up. Chronic disease management records were in place for diabetic
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
Review procedures for creating and maintaining current medication lists
to avoid duplication.
Consider extending the use of chronic disease management forms