20 FEBRUARY, 2010 - Today , the Cosed Medical Records Review summary done last January 13th 2010 was presented to the department QA this morning by Dr R Edusma - the summary of which is furnished below:
NUMBER OF CHARTS REVIEWED: 19
|
CHART CONTENT |
YES |
INC |
NO |
NA |
REMARKS |
|
Informed consent for surgery |
2/2 (100%) |
|
|
17 |
|
|
Informed consent for procedures |
7/8 (87.50%) |
|
1/8 (12.50%) |
11 |
No consent for chemotherapy |
|
Informed consent for blood transfusion |
4/5 (80%) |
|
1/5 (20%) |
14 |
|
|
Informed consent for anesthesia, moderate and deep sedation |
4/6 (66.66%) |
|
2/6 (33.33%) |
13 |
Indicate sedation plan in consent for procedure; not written |
|
Consent to treatment certification document
|
2/2 (100%) |
|
|
16 |
1 form not filled up |
|
Patient education
|
5/18 (27.77%) |
1/18 (5.55%) |
12/18 (66.66%) |
|
1 form not filled up/left blank |
|
Chief complaint and history of present illness |
13/19 (68.42%) |
1/19 (5.26%) |
5/19 (26.32%) |
|
|
|
Review of systems |
9/19 (47.37%) |
1/19 (5.26%) |
9/19 (47.37%) |
|
|
|
Past medical history, including list of meds |
13/19 (68.42%) |
1/19 (5.26%) |
5/19 (26.32%) |
|
Patient not seen by medical resident |
|
Family history |
11/19 (57.89%) |
1/19 (5.26%) |
7/19 (36.84%) |
|
Please do not use abbreviation such as “U/R” |
|
Social and personal history |
13/19 (68.42%) |
1/19 (5.26%) |
5/19 (26.32%) |
|
|
|
Physical examination |
13/19 (68.42%) |
1/19 (5.26%) |
5/19 (26.32%) |
|
|
|
Admitting diagnosis |
13/19 (68.42%) |
1/19 (5.26%) |
5/19 (26.32%) |
|
|
|
Care plan |
6/19 (31.58%) |
1/19 (5.26%) |
12/19 (63.16%) |
|
|
|
Mental status, psychological evaluations |
2/5 (40%) |
|
3/5 (60%) |
13 |
1- not filled up |
|
Report of consultation for referrals
|
4/11 (36.36%) |
3/11 (27.27%) |
4/11 (36.36%)
|
8 |
No plan consult sheet; No endocrine consult form; No reason for referral, conclusion and signature of AMD |
|
Updated problem list |
11/18 (61.11%) |
|
7/18 (38.88%) |
1 |
No pulmo consult sheet |
|
Daily progress notes (SOAP): House staff |
12/18 (66.66%) |
|
6/18 (33.33%) |
1 |
Not countersigned by Attending Physician |
|
Daily progress notes(SOAP): Medical staff
|
14/18 (77.77%) |
|
4/18 (22.22%) |
1 |
|
|
Progress notes for unexpected outcomes/adverse events |
1/1 (100%) |
|
|
18 |
|
|
Pre-operative assessment |
2/2 (100%) |
|
|
17 |
|
|
Assessment for Cardio clearance |
3/4 (75%) |
|
1/4 (25%) |
15 |
Cleared in order sheet, but no consultation sheet |
|
Assessment for Pulmonary clearance |
2/2 (100%) |
|
|
17 |
|
|
Assessment for Endocrine clearance |
1/2 (50%) |
|
1/2 (5%) |
17 |
|
|
Assessment for Hematology clearance |
|
|
|
19 |
|
|
Other clearances
|
1/1 (100%) |
|
|
17 |
1 not filled up |
|
Pre-operative anesthetic assessment |
1/1 (100%) |
|
|
16 |
2 not filled up
|
|
Anesthesia Plan |
|
|
1/1 (100%) |
15 |
|
|
Anesthesia Record
|
3/3 (100%) |
|
|
16 |
|
|
Surgical safety checklist
|
|
|
1/1 (100%) |
18 |
|
|
Surgical report: Description of procedure/findings/specimen |
3/3 (100%) |
|
|
16 |
|
|
Post-operative Diagnosis |
3/3 (100%) |
|
|
16 |
|
|
Name of surgeon/assist |
3/3 (100%) |
|
|
16 |
|
|
Legibly written entries in: H&P/Report of consult/Discharge summary |
14/19 (73.68%) |
1/19 (5.26%) |
4/19 (21.05%) |
|
|
|
Progress notes |
13/18 (72.22%) |
2/18 (11.11%) |
3/18 (16.66%) |
1 |
|
|
Physician’s orders |
18/19 (94.74%) |
|
1/19 (5.26%) |
|
|
|
Tel/verbal orders countersigned within 24 hrs |
4/10 (40%) |
3/10 (30%) |
3/10(30%) |
9 |
|
|
Discharge plan include: |
|
|
|
|
- |
|
May go home order |
16/19 (84.21%) |
|
3/19 (15.79%) |
|
Other MD’s have no signature over their telephone orders |
|
Home medications (if applicable) |
16/19 (84.21%) |
|
3/19 (15.79%) |
|
|
|
Follow up visits/schedule |
15/18 (83.33%) |
|
3/18 (16.66%) |
1 |
|
|
Home care/advise
|
13/17 (76.47%) |
|
4/17 (23.53%) |
2 |
|
|
Discharge summary that includes: |
|
|
|
|
|
|
Reason for admission |
1/18 (5.55%) |
1/18 (5.55%) |
16/18 (88.88%) |
1 |
Form not inserted |
|
Significant physical and other findings |
1/18 (5.55%) |
1/18 (5.55%) |
16/18 (88.88%) |
1 |
Form not inserted |
|
Diagnostic and therapeutic procedures performed |
1/18 (5.55%) |
1/18 (5.55%) |
16/18 (88.88%) |
1 |
Form not inserted |
|
Significant medications and other treatments |
1/18 (5.55%) |
1/18 (5.55%) |
16/18 (88.88%) |
1 |
No discharge summary form inserted in the chart |
|
Patient’s condition at the time of discharge |
1/18 (5.55%) |
1/18 (5.55%) |
16/18 (88.88%) |
1 |
Form not inserted |
|
Discharge medications |
1/18 (5.55%) |
1/18 (5.55%) |
16/18 (88.88%) |
1 |
Form not inserted |
|
Follow-up instructions |
|
1/18 (5.55%) |
17/18 (94.44%) |
1 |
Form not inserted |
|
Final diagnosis |
7/18 (38.88%) |
2/18 (11.11%) |
9/18 (50%) |
1 |
No counter signature |
|
Transferred patients: Name of receiving hospital |
|
|
|
19 19 |
|
|
Reason/s for transfer |
|
|
|
19 |
|
|
Special condition related to transfer |
|
|
|
19 |
|
|
Change of patient condition during transfer
|
|
|
|
19 |
|
|
COMMENTS ON CHART REVIEW |
REMARKS |
|
1. It is highly recommended to insert checklist of documents in each chart for better monitoring of completion charts prior to patient’s discharge by hospital staff. 2. Patient not seen by medical resident. 3. No signature of admitting resident (allergy sheet) 4. Not countersigned order (telephone) on may go home date. 5. No discharge summary form inserted on the chart. 6. No countersign of orders at discharge |
Kindly mark NO when the item is not found in the chart (ex. No problem List), or in the appropriate form (No Discharge Medications written) instead of INC.
Please mark all spaces provided for the checklist whether YES, INC, NO, NA.
For the next reviews, kindly write the name of the Resident (House staff) or Medical Staff incurring a No or INC (ex. Tel. order not countersigned by Dr. Juan Dela Cruz)
|
//cdc/jan2010/TQS
