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V. Structure and Organization

o

High

o

Meets

o

Significant Improvements

of Medical Records

Standard Standard Required

Comments

:

Dr. Good maintains very good medical records. Files

are kept in alphabetical order so it’s easy to find them.

The chart contents are well organized. The left side of

the chart includes consultation reports, medication lists

and a registration sheet. The right side of the chart

includes progress notes and lab results. The name of

the patient, the dates, and the doctor’s signature is

present on every sheet in the file. Progress notes are

handwritten and legible. From reviewing the progress

notes it is possible to determine why the patient came

to see the doctor, what observations were made,

and what was done. In addition, significant negative

findings are recorded. In the majority of files reviewed

there were typed consultation reports. In addition,

discharge summaries are typed and contain all the

relevant information including history, progress in

hospital, diagnosis and treatment plan. Lab results are

initialed. Telephone calls with patients are recorded in

the file.

Concerns:

Currently allergies are

not included in the

registration sheet in

outpatient files.

Suggestions:

To add an allergy section to the registration sheet in

outpatient files.

Action Taken By

Physician Assessed:

VI. A.Specialist Patient Questionnaire

(44 out of 60 questionnaires returned)

The feedback from Dr. Good’s patients is indeed very positive and it shows great

satisfaction with the care they receive from him.

VI. B.Referring Physician Questionnaire

(15 out of 20 questionnaires

returned)

Referring physicians are very satisfied with Dr. Good and the staff at the Small Town

Mental Health Centre. They find him to be accessible for routine and emergency

consultations, and they find the call arrangement to be acceptable.