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16

PRACTICE ENHANCEMENT PROGRAM

3. What The Assessor Looks For . . .

1.

Quality of Care

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Documented investigation appropriate to patient’s complaint/condition

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Appropriate diagnoses are reached

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Management plan and medication prescribed are appropriate to

condition being treated

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Indications for surgical and other procedures are documented and

appropriate

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Adequacy of treatment of both acute and chronic conditions

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Counselling and psychotherapeutic sessions are appropriately indicated

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Utilization of support and community resources

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Practice guidelines are being followed

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Evidence of appropriate investigations and follow-up of results

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Assessment of lifestyle and preventive health issues

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Arrangements are made for the physician’s patients to be cared for in

his/her absence

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Emergency problems are dealt with promptly and effectively

2.

Medical Records

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Adequate notes for reader to follow present management

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Stress quality of legibility

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Patient identity is clearly evident on each chart component

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Describe organization within charts, retrieval of items

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Use of standard forms (cumulative patient profile, flow sheets,

medications, history summary, etc.)

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S.O.A.P. type or narrative notes covering all areas

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Diagnosis and treatment plan are clearly stated

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Allergies and drug reactions clearly documented, as well as dates of

immunizations

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Documentation of medications – type, duration, evidence of regular

review

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Significant positive and negative findings are recorded

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System for acknowledgement and follow-up of abnormal test results

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Retention of pathology reports, hospital discharge summaries,

operative notes, etc.

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Use of pediatric growth charts and Saskatchewan Prenatal Forms

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Documented evidence that periodic general assessments are

performed

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Documented evidence that lifestyle and health maintenance issues are

discussed

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Identification of physicians making chart entries

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Evidence of progress notes for management of chronic conditions

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Recording in charts of significant telephone advice given

3.

Physical Facilities and Practice Organization

a.

General Office Facilities

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Adequacy of total area - describe size, design, atmosphere,

cleanliness, maintenance

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Accessibility – wheelchair, parking, etc.