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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

lifestyle counselling.

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.