TMC Service Clinic Documentation Rounds APRIL-JUNE 2015 MA. CRISTINA TUAZON, MD TMC Department of PEDIATRICS

Methodolog y  Random patient charts from each department were gathered  Ten (10) charts per month:  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

AprilMayJune DepartmentPDFPNCIPDFPNCIPDFPNCI Medicine Surgery N/A Pedia OB-Gyne ENT Ophtha Neurology Ortho Table 1: Random Chart Review Scores per Department

Figure 1: Patient Database Form Scores for April, May, June

Observations: Patient Database Form  Good Job (almost complete)  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

Figure 2: Progress Note Scores for April, May, June

Observations: Progress Notes  Good Job  Relevant subjective entries  Relevant physical exam  Needs improvement  Plans formulated were congruent with assessment done  Which includes: diagnostic, therapeutic, supportive  Patient education and follow up

Figure 3: Clinical Indication Scores for April, May, June

Observations: Clinical Indications  MOST OMITTED PART  Needs improvement  Clinical indications for diagnostic tests, procedures, medications

RECOMMENDATIONSRECOMMENDATIONS 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!