Emergency Room Provider Chart Review Tool

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"]