Task Mini Chart Audit
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1Name of Resident: ___________Name of Assessor_________________
Date:_________
Task
|
Mini Chart Audit
Today’s focus is on charting.
(CM2.1) T
The attending physician should randomly select TWO charts to audit. Should take 5-6 minutes to complete.
The charts (or temporary copies) of the charts should be held until a point in the shift where feedback can be ef-
fectively given with both resident and attending physician reviewing the chart.
CHART 1
CHART 1
CHART 1
CHART 2
CHART 2
CHART 2
DONE BUT
DONE BUT
CHECKLIST
CHECKLIST
NOT
NOT
DONE
NEEDS
DONE
NEEDS
DONE
DONE
ATTENTION
ATTENTION
Completes all basic identifiers (Self, Attending, Date, Times)
Information relevant to CC and HPI recorded
Physical Examination - relevant systems
Physical Examination - documents specific elements; avoids broad
How well did the resident perform this task?
sweeping generalizations
Relevant Investigations (e.g. ECG, relevant labs, Imaging indicated)
Documents procedures e.g. type of closure, suture type, anesthetic - type
and dose
Reassessments documented (including time); changes noted
Disposition plan documented (e.g. Consultation time/discussion; Discharge
Instructions - relevant and appropriate; Rx or continuation orders as
appropriate)
Completion of Ancillary Paperwork (Rx, referral forms, etc..)
RATE THIS TASK |
RATE THIS TASK |
RATE THIS TASK |
RATE THIS TASK |
RATE THIS TASK |
RATE THIS TASK |
RATE THIS TASK |
CIRCLE NUMBER THAT THAT BEST DESCRIBES LEVEL OF PROFICIENCY
CIRCLE NUMBER THAT THAT BEST DESCRIBES LEVEL OF PROFICIENCY
CIRCLE NUMBER THAT THAT BEST DESCRIBES LEVEL OF PROFICIENCY
CIRCLE NUMBER THAT THAT BEST DESCRIBES LEVEL OF PROFICIENCY
CIRCLE NUMBER THAT THAT BEST DESCRIBES LEVEL OF PROFICIENCY
CIRCLE NUMBER THAT THAT BEST DESCRIBES LEVEL OF PROFICIENCY
CIRCLE NUMBER THAT THAT BEST DESCRIBES LEVEL OF PROFICIENCY
1
2
3
4
5
6
7
Needs Assistance in area
Requires significant charting by
Requires minimal charting by
Ready for Next Steps
Requires extensive charting by
attending to rectify charting.
attending to clarify charting.
Attending documents no additional
attending to compensate for
or further information that is not
missing items.
already contained in the chart.
Resident’s chart is
Resident’s chart is roughly
Resident’s chart is
Resident’s chart is described by
described by ANY of the
described by the below:
roughly described by the
ALL of the below:
below:
below:
• Charting fails to provide a
• Charting provides a thorough
• Charting is incomplete and
thorough narrative of the
• Charting provides a
narrative of the patient-doctor
missing key items (noted
patient-doctor encounter in
complete narrative of
encounter in the ED.
above).
the ED but to incorporates
the patient-doctor
• Chart provides a succinct and
parts all the important
encounter in the ED.
• Chart fails to provide a
nuanced synthesis that fully
elements.
synthesis of the resident’s
• Confusing, but still is
explains the resident’s
decision-making and
• Chart fails to provide a
able to convey the
decision-making & thinking
thinking process.
synthesis of the resident’s
overall thinking process
process.
decision-making & thinking
to external reader.
• Inefficient/verbose, illegible
• Efficient, legible
process.
or incoherent
• Efficient, legible
documentation.
documentation.
• Hard to read.
documentation.
The Evidence: Please provide an example of the learner’s behaviour with an explanation that supports your rating. Add enough details
to ensure another faculty member can quickly understand your rationale for the above score. (MANDATORY)
The next step: Based on the above evidence, please give one specific suggestion (Education Prescription) for the resident to attempt
during his/her next shift.
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