Sample Quality Chart Review Tool (Page 2 of 2) in pdf

Sample Quality Chart Review Tool Page 2

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Documentation of the informed consent process, when

applicable

Documentation of phone encounters

Patient allergies (medications, food, latex, etc.) are listed on

an allergy sticker or other form easily visible in the chart.

Completed Medication List

Prescription refills

An initial medical/surgery/social history – updated as

appropriate.

Dispensed sample drugs are entered and include dosage,

name, and quantity.

Preventive health screens are documented such as

immunizations, pap smears, PSAs, lipid profiles, etc.

All lab tests and diagnostic imaging results are in the chart,

dated and initialed by the practitioner ordering the tests.

Documentation of communication and failed communication

efforts to the patient regarding all labs, diagnostic procedure

results & referral results.

Documentation of referral results.

Progress note for each encounter.

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1. Patient’s name, date and time

2. Practitioner’s signature and/or initials

3. Primary complaint or reason for visit

4. Vital signs as appropriate

5. Current medications

6. Current allergies

7. Positive and pertinent negative findings

8. Diagnosis/impression

9. Studies ordered

10. Therapy administered including new prescriptions

11. Patient disposition/instructions

12. Copies of or reference to printed materials, if applicable

13. Referral information if applicable

14. Updated problem list

15. Written notes are legible

Sample Quality Chart Review Tool Page 2