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8. Encourage the use of pediatric growth charts for both newborn and pediatric

patients. Recommend on newborn visits that head circumference and length

be documented as well as weight.

• Five pediatric charts were reviewed. Dr. XXXXX is now using a growth

chart. Only one newborn record was reviewed. This was patient K.H.

There was no evidence of head circumference head measurement being

recorded and followed.

• Consistently utilize and maintain Pediatric Growth Charts.

9. Suggest for diabetic patients regular assessment of micro albuminuria, serum

creatinine electrolytes urinalysis and cholesterol profiles with treatment

to target goals for lipids. Regular diabetic eye examinations should be

documented.

• Five diabetic charts were reviewed. There is fairly consistent

absence of

assessment

of micro albuminuria on the diabetic charts. The majority

of charts are followed by serum creatinine, electrolytes, urinalysis, and

cholesterol profiles. Cholesterol profiles are not always treated to target

goals for lipids. The patient chart of S.G. indicates a newly diagnosed

diabetic as of September 2003. She had transferred from another

physician to Dr. XXXXX’s care and had visits December 3, 8, 16, 23, 2003

and January and March 2004. There were no blood pressures recorded.

No lifestyle changes were recorded. A hemoglobin A1C was recorded.

There was no micro albuminuria and no electrolytes recorded. Her lipids

had not been checked since being at Dr. XXXXX’s office but on review

of old records, the previous physician had indicated that the patient did

have unacceptable cholesterol levels that he had planned on addressing

but this had not been followed up in Dr. XXXXX’s office. There was no

documentation of an eye examination. Regular diabetic eye examinations

were found on some diabetic charts but not all.

• Management in this area is severely lacking.

10. More complete documentation of diagnostic criteria for depression as well as

documentation of inquiry regarding suicidal ideation

• Three psychiatric charts were reviewed. There is minimal evidence of

documentation of diagnostic criteria for depression. Suicidal ideation was

not recorded.

The assessee met meet with Dr. XXXXX following the reassessment to review the

findings. The lack of documentation on the chart of positive and negative findings

was indicated to him. Dr. XXXXX responded that he did not understand what that

recommendation was. This was explained to him with the use of chart example

patient B.C. where no blood pressures were recorded on any visits, even after

recommendations from the specialist and the introduction of an NSAID medication

for arthritic complaints. The example of charting only the sentence “short of

meds” with a list of renewal of medications was also used as an example. The

importance of recording positive and negative findings, especially a blood pressure

measurement was explained. Also discussed was the lack of a cumulative patient

profile and flow sheet on any of the patient records. Dr. XXXXX indicated that

he had recently called the Practice Enhancement Program and had been sent an

example of flow sheets which he was now introducing into new patient charts.