Transcript TMC Service Clinic Documentation Rounds

TMC Service Clinic
Documentation
Rounds
APRIL-JUNE 2015
MA. CRISTINA TUAZON, MD
TMC Department of PEDIATRICS
 Random patient charts from each department were
gathered
 Ten (10) charts per month:
Methodolog
y
April
May
June
 Each chart was graded using the TMC
Documentation Rounds Form
Documentation
Charts
Form
 Three Criteria
Patient Database Form
 10 pts
Progress Notes
 5pts
Clinical Indication
 1pt
Perfect Score: 16
Table 1: Random Chart Review Scores per
Department
April
May
June
Department PDF
PN
CI
PDF
PN
CI
PDF
PN
CI
Medicine
7.00
1.00
1.00
7.00
5.00
0.00
5.00
2.00
0.00
Surgery
8.00
4.00
0.00
7.00
2.00
0.00
N/A
N/A
N/A
Pedia
7.00
4.00
0.00
8.00
4.00
0.00
7.00
4.00
0.00
OB-Gyne
6.00
4.00
0.00
9.00
5.00
0.00
8.00
4.00
0.00
ENT
10.00
5.00
1.00
8.00
4.00
1.00
2.00
3.00
0.00
Ophtha
7.00
3.00
0.00
8.00
2.00
0.00
9.00
5.00
1.00
Neurology
6.00
2.00
1.00
0.00
0.00
0.00
5.00
3.00
0.00
Ortho
5.00
2.00
0.00
7.00
4.00
0.00
8.00
5.00
0.00
Patient Database Form
12.00
2015 APRIL
2015 MAY
2015 JUNE
10.00
Figure 1:
8.00
Patient
Database Form
Scores
for
April, May, June
6.00
4.00
2.00
0.00
Medicine
Surgery
Pedia
OB-Gyne
ENT
Ophtha Neurology
Ortho
 Good Job (almost complete)
Observations:
Patient
Database Form
History of present illness
Review of System
Complete Physical Exam
Diagnosis
 Tendency to omit (Needs improvement)
Past medical history
Family history
Personal history
 Pain score
Plan of Care
Follow up
Progress Notes
6.00
2015 APRIL
2015 MAY
2015 JUNE
5.00
Figure 2:
Progress Note
Scores
for
April, May, June
4.00
3.00
2.00
1.00
0.00
Medicine
Surgery
Pedia
OB-Gyne
ENT
Ophtha
Neurology
Ortho
 Good Job
Relevant subjective entries
Relevant physical exam
Observations:
 Needs improvement
Progress Notes
Plans formulated were congruent with
assessment done
 Which includes: diagnostic, therapeutic,
supportive
Patient education and follow up
Clinical Indication
1.20
2015 APRIL
2015 MAY
2015 JUNE
1.00
Figure 3:
Clinical
Indication
Scores
for
April, May, June
0.80
0.60
0.40
0.20
0.00
Medicine
Surgery
Pedia
OB-Gyne
ENT
Ophtha Neurology
Ortho
 MOST OMITTED PART
Observations:
Clinical
Indications
 Needs improvement
Clinical indications for diagnostic tests, procedures,
medications
R
E
C
O
M
M
E
N
D
A
T
I
O
N
S
• Patient Database Form
May write your PMH immediately after the HPI
Always remember to tick “unremarkable” in the Review of Systems
Write Plan of Care (Diagnostic Plans, Therapeutic and Supportive Plans) with their
clinical indications
Always remember to finalize every entry to save the file
• Progress Notes
Always indicate the plan for the patient and follow up
• Clinical Indications
JCI requirement:
 to write the indications for our diagnostic tests, procedures, medications
Thank You
&
HAVE A BLESSED
DAY!