his blood pressure and had been referred to Dr. YYYYY for review. He was
seen in Dr. YYYYY’s office in September 2003. Dr. YYYYY had commented
that his blood pressure was not at target and had recommended a change
in medication dose. The patient had returned to Dr. XXXXX’s office on
seven occasions since October 2003 but no blood pressure was recorded.
He was visiting the office for joint related complaints and not specifically
blood pressure checks but an NSAID was started for treatment for the
main complaint with no blood pressure recorded. A common finding on
charts was that the chief complaint was “short of meds” with a list of
medications that were renewed and for the duration of renewal but no
positive or negative findings recorded.
• Expand documentation on the chart on a more regular basis for positive
and negative findings.
5. Discussion with patients in regards to lifestyle changes, i.e. smoking,
exercise, weight loss and alcohol intake should be consistently documented.
• Lifestyle changes i.e. smoking, exercise, weight loss and alcohol intake
were usually consistently documented when a complete physical
examination was completed. In the absence of the complete physical
examination no mention was made of discussion with patients in regards
to lifestyle changes to improve medical condition and care.
• Emphasize discussion and documentation of preventative medicine and
6. Recommend the use of flow sheets, i.e. medication flow sheets, laboratory
flow sheets and cumulative patient profiles.
• Of the 38 charts reviewed there were
no flow sheets
in the form of
medication flow sheets, laboratory flow sheets or cumulative patient
• Consistently use and maintain a Cumulative Patient Profile to provide
continuity of care.
• Develop a medication flow sheet to include a full list of medications
prescribed, refill dates, duration of and amount of prescriptions, indication
of maximum period for refill, etc.
• The selective use of laboratory flow sheets is strongly encouraged to allow
a quick overview of the trends in laboratory testing. Consistently use
flow sheets to provide unity in the record and to facilitate management of
chronic disease conditions.
7. Suggest more complete record keeping on prenatal sheets along with risk
scoring. Recommend offering or educating prenatal patients in terms of
options for maternal serum screening tests.
• Of the prenatal charts that were reviewed there was complete record
keeping on the prenatal charts along with risk scoring.