Emergency Room Provider Chart Review Tool

General & Administrative
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EMERGENCY ROOM PROVIDER CHART REVIEW TOOL
[text default="chart #"] <-- Visit Identifier
[date] <-- Visit Date
[text] <-- Visit Provider
[text] <-- Reviewer
[date] <-- Review Date
[text] <-- 1. Patient age
[select name="Q2" value="yes|no|uncertain|not applicable"] <-- 2. Medical screening exam sufficient[conditional field="Q2" condition="(Q2).is('no')||(Q2).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q3" value="yes|no|uncertain|not applicable"] <-- 3. Documentation of the absence or presence of an Emergency Medical Condition[conditional field="Q3" condition="(Q3).is('no')||(Q3).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q4" value="yes|no|uncertain|not applicable"] <-- 4. History of present illness is sufficient and addresses significant subjective complaints[conditional field="Q4" condition="(Q4).is('no')||(Q4).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q5" value="yes|no|uncertain|not applicable"] <-- 5. Pain assessment sufficient[conditional field="Q5" condition="(Q5).is('no')||(Q5).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q6" value="yes|no|uncertain|not applicable"] <-- 6. Allergies documented[conditional field="Q6" condition="(Q6).is('no')||(Q6).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q7" value="yes|no|uncertain|not applicable"] <-- 7. Review of Systems sufficient[conditional field="Q7" condition="(Q7).is('no')||(Q7).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q8" value="yes|no|uncertain|not applicable"] <-- 8. Physical exam sufficient[conditional field="Q8" condition="(Q8).is('no')||(Q8).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q9" value="yes|no|uncertain|not applicable"] <-- 9. Abnormal vital signs and/or physical findings addressed[conditional field="Q9" condition="(Q9).is('no')||(Q9).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q10" value="yes|no|uncertain|not applicable"] <-- 10. Appropriate Labs, Radiology, and Special Studies (e.g. EKG) obtained and addressed[conditional field="Q10" condition="(Q10).is('no')||(Q10).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q11" value="yes|no|uncertain|not applicable"] <-- 11. Reassessment of patient’s condition after treatment interventions (e.g. nebs/pain/etc)[conditional field="Q11" condition="(Q11).is('no')||(Q11).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q12" value="yes|no|uncertain|not applicable"] <-- 12. Assessment and plan appropriate and clearly documented[conditional field="Q12" condition="(Q12).is('no')||(Q12).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q13" value="yes|no|uncertain|not applicable"] <-- 13. Appropriate patient education provided[conditional field="Q13" condition="(Q13).is('no')||(Q13).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q14" value="yes|no|uncertain|not applicable"] <-- 14. Disposition appropriate (discharge, admission, or transfer)[conditional field="Q14" condition="(Q14).is('no')||(Q14).is('uncertain')"]
COMMENT: [text][/conditional]
OVERALL COMMENTS: [text size=100]
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:

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