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
• Five diabetic charts were reviewed. There is fairly consistent
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
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.