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Practice Enhancement Program

Medical Office Assessment Form

Name of Physician Assessed:

Phys I.D. _______

Name of Assessor:

Date of Assessment:

Definitions - For the purpose of this report

N/A

not applicable or not answered

Always

self-explanatory

Usually

means in MORE than 50% of files reviewed

Sometimes

means in LESS than 50% of files reviewed

Never

self-explanatory

A. QUALITY OF THE PHYSICIAN’S CARE

Note: If you find evidence of inadequate patient care, please identify the

patient’s name and chart number to support your opinion.

Always Usually Sometimes Never N/A

1. The documented investigation is appropriate

o

o

o

o

o

to complaint/condition.

2. The documented chief complaint, history, physical

o

o

o

o

o

findings and investigation reports lead to the

making of an appropriate diagnosis.

3. The management plan (

excluding prescribed

o

o

o

o

o

medication)

is appropriate to the condition

being treated.

4. The medication prescribed is appropriate to the

o

o

o

o

o

condition being treated.

5. The indications for surgical, obstetrical,

gynecological

o

o

o

o

o

and other procedures are documented (

if relevant

).

6. a) Adequacy of treatment including follow up care

o

o

o

o

o

of acute conditions.

b) Adequacy of treatment including follow up care

o

o

o

o

o

for chronic conditions.

7. Counselling sessions are appropriately

ocumented and indicated.

o

o

o

o

o

6.d Office Assessment Checklist R-2