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EMERGENCY ROOM PROVIDER CHART REVIEW TOOL
[text default="chart #" name="variable_1"] <-- Visit Identifier
[date name="variable_2"] <-- Visit Date
[text name="variable_3"] <-- Visit Provider
[text name="variable_4"] <-- Reviewer
[date name="variable_5"] <-- Review Date
[text name="variable_6"] <-- 1. Patient age
[select name="variable_7" value="yes|no|uncertain|not applicable"] <-- 2. Medical screening exam sufficient[conditional field="variable_7" condition="(variable_7).is('no')||(variable_7).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_8" value="yes|no|uncertain|not applicable"] <-- 3. Documentation of the absence or presence of an Emergency Medical Condition[conditional field="variable_8" condition="(variable_8).is('no')||(variable_8).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_9" value="yes|no|uncertain|not applicable"] <-- 4. History of present illness is sufficient and addresses significant subjective complaints[conditional field="variable_9" condition="(variable_9).is('no')||(variable_9).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_10" value="yes|no|uncertain|not applicable"] <-- 5. Pain assessment sufficient[conditional field="variable_10" condition="(variable_10).is('no')||(variable_10).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_11" value="yes|no|uncertain|not applicable"] <-- 6. Allergies documented[conditional field="variable_11" condition="(variable_11).is('no')||(variable_11).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_12" value="yes|no|uncertain|not applicable"] <-- 7. Review of Systems sufficient[conditional field="variable_12" condition="(variable_12).is('no')||(variable_12).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_13" value="yes|no|uncertain|not applicable"] <-- 8. Physical exam sufficient[conditional field="variable_13" condition="(variable_13).is('no')||(variable_13).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_14" value="yes|no|uncertain|not applicable"] <-- 9. Abnormal vital signs and/or physical findings addressed[conditional field="variable_14" condition="(variable_14).is('no')||(variable_14).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_15" value="yes|no|uncertain|not applicable"] <-- 10. Appropriate Labs, Radiology, and Special Studies (e.g. EKG) obtained and addressed[conditional field="variable_15" condition="(variable_15).is('no')||(variable_15).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_16" value="yes|no|uncertain|not applicable"] <-- 11. Reassessment of patient’s condition after treatment interventions (e.g. nebs/pain/etc)[conditional field="variable_16" condition="(variable_16).is('no')||(variable_16).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_17" value="yes|no|uncertain|not applicable"] <-- 12. Assessment and plan appropriate and clearly documented[conditional field="variable_17" condition="(variable_17).is('no')||(variable_17).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_18" value="yes|no|uncertain|not applicable"] <-- 13. Appropriate patient education provided[conditional field="variable_18" condition="(variable_18).is('no')||(variable_18).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="variable_19" value="yes|no|uncertain|not applicable"] <-- 14. Disposition appropriate (discharge, admission, or transfer)[conditional field="variable_19" condition="(variable_19).is('no')||(variable_19).is('uncertain')"]
COMMENT: [text][/conditional]
OVERALL COMMENTS: [text size=100 name="variable_20"]
EMERGENCY ROOM PROVIDER CHART REVIEW TOOL
<-- Visit Identifier
<-- Visit Date
<-- Visit Provider
<-- Reviewer
<-- Review Date
<-- 1. Patient age
<-- 2. Medical screening exam sufficient
<-- 3. Documentation of the absence or presence of an Emergency Medical Condition
<-- 4. History of present illness is sufficient and addresses significant subjective complaints
<-- 5. Pain assessment sufficient
<-- 6. Allergies documented
<-- 7. Review of Systems sufficient
<-- 8. Physical exam sufficient
<-- 9. Abnormal vital signs and/or physical findings addressed
<-- 10. Appropriate Labs, Radiology, and Special Studies (e.g. EKG) obtained and addressed
<-- 11. Reassessment of patient’s condition after treatment interventions (e.g. nebs/pain/etc)
<-- 12. Assessment and plan appropriate and clearly documented
<-- 13. Appropriate patient education provided
<-- 14. Disposition appropriate (discharge, admission, or transfer)
OVERALL COMMENTS:
Result - Copy and paste this output: