Chart audit

Clinic File Audit Patient: XYZ File 00010 Comments Are intake forms present and complete? X Yes Intern did take into consideration the intake forms and they were all complete.
No
Somewhat
Is patient consent in place?
Yes
No
X
Somewhat
Not all the forms had patient consent on them.
Was a physical exam performed within last 12 months?
Yes
X
No
Physical exam forms were missing; a sign that the intern did not conduct a physical examination
Somewhat
Were all significant problems identified on problem list, Cautions or management plan?
Yes
No
X
Somewhat
Not all significant problems were for instance history of illness was mentioned anywhere
Does the level of detail for the patient history seem appropriate for the case? For instance, are appropriate follow up questions and questions to rule out red or yellow flags addressed?
Yes
X
No
As mentioned above, the patient detail is not enough to address red or yellow flag. As information are missing; the history of illness is nowhere to be found
Somewhat
Do the examination procedures performed make sense in light of the history? Meaning, were extraneous tests performed? Were necessary tests omitted?
Yes
X
No; no history of illness was taken making it hard to perform sensible test
A complete health assessment includes gathering information about a persons medical history and lifestyle, doing laboratory tests, and screening for disease. This was never done by the intern
Somewhat
Were special studies utilized appropriately? This includes ordering appropriately, following up, obtaining results, etc.
X
Yes
The intern did a thorough job in regard to utilizing special studies
No
Somewhat
Is the diagnosis or differential diagnoses appropriate, based on the history, exam, and special studies?
Yes
X
No
The diagnosis is not appropriate since the intern forgot to do history examination
Somewhat
Is the management plan reasonable and consistent with diagnosis?
X
Yes
The plan is reasonable and consistent; Was pretty consistent. Only minor marking was missing on the human diagram where complaints were
No
Somewhat
Are re-assessments performed, utilizing appropriate out- come measures, in a reasonable amount of time, given patients status; and was the management plan changed accordingly?
X
Yes
Re-assessments were done by the intern based on the patient’s status; this helped in managing the plan well
No
Somewhat
Were proper recommendations (nutrition, home activities, etc.) given?
X
Yes
The intern gave wonderful recommendations that included home exercises and other activities to boost good health
No
Somewhat
Was patient referred to another practitioner when necessary?
Yes
X
No
No the patient was never referred to another practitioner
Somewhat
Was patient discharge being documented approximately?
X
Yes
Yes the patient discharge was clearly documented as per the set guidelines in the hospital
No
Somewhat
SUMMARY
Based on the patient’s chart given above, it is clear that the intern took into account most of the key procedure required. However, the intern was not close to 100%. Patient consent is an important ethical consideration in a medical field, the intern never filled all the patients’ consent forms; this could be attributed to the interns lack of proper knowledge in regard to the importance of the patients’ forms. It is important to note that the intern failed to analyze history of illness, this could have led to possible lead towards diagnostic tests to be conducted; in future the intern needs to be explained to the importance of analyzing the patient’s historical illness to help him form a basis of diagnosis.
In overall, the intern could perform much better if the above mentioned problems are taken into account. Otherwise the intern’s performance was above average.