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

2. 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

4. Documentation Charts Form  Three Criteria  Patient Database Form  10 pts  Progress Notes  5pts  Clinical Indication  1pt Perfect Score: 16

5. AprilMayJune DepartmentPDFPNCIPDFPNCIPDFPNCI Medicine7.001.00 7.005.000.005.002.000.00 Surgery8.004.000.007.002.000.00N/A Pedia7.004.000.008.004.000.007.004.000.00 OB-Gyne6.004.000.009.005.000.008.004.000.00 ENT10.005.001.008.004.001.002.003.000.00 Ophtha7.003.000.008.002.000.009.005.001.00 Neurology6.002.001.000.00 5.003.000.00 Ortho5.002.000.007.004.000.008.005.000.00 Table 1: Random Chart Review Scores per Department

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

7. 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

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

9. 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

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

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

12. 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

13. Thank You & HAVE A BLESSED DAY!