Outpatient Provider Chart Review Tool

General & Administrative
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OUTPATIENT 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. History of present illness is sufficient[conditional field="Q2" condition="(Q2).is('no')||(Q2).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q3" value="yes|no|uncertain|not applicable"] <-- 3. Past medical history is documented[conditional field="Q3" condition="(Q3).is('no')||(Q3).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q4" value="yes|no|uncertain|not applicable"] <-- 4. Medication reconciliation is documented[conditional field="Q4" condition="(Q4).is('no')||(Q4).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q5" value="yes|no|uncertain|not applicable"] <-- 5. Allergies documented[conditional field="Q5" condition="(Q5).is('no')||(Q5).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q6" value="yes|no|uncertain|not applicable"] <-- 6. Review of Systems sufficient[conditional field="Q6" condition="(Q6).is('no')||(Q6).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q7" value="yes|no|uncertain|not applicable"] <-- 7. Vital Signs are documented and repeated if appropriate[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. Lab-work and special studies are appropriately ordered[conditional field="Q10" condition="(Q10).is('no')||(Q10).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q11" value="yes|no|uncertain|not applicable"] <-- 11. Available Lab-work and special studies are interpreted and documented[conditional field="Q11" condition="(Q11).is('no')||(Q11).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q12" value="yes|no|uncertain|not applicable"] <-- 12. Documentation of Informed Consent prior to procedure[conditional field="Q12" condition="(Q12).is('no')||(Q12).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q13" value="yes|no|uncertain|not applicable"] <-- 13. Assessment is appropriate and supported by history, exam, and studies[conditional field="Q13" condition="(Q13).is('no')||(Q13).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q14" value="yes|no|uncertain|not applicable"] <-- 14. Plan is appropriate[conditional field="Q14" condition="(Q14).is('no')||(Q14).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q15" value="yes|no|uncertain|not applicable"] <-- 15. Education documented (disease/treatment/side effects)[conditional field="Q15" condition="(Q15).is('no')||(Q15).is('uncertain')"]
COMMENT: [text][/conditional]
[select name="Q16" value="yes|no|uncertain|not applicable"] <-- 16. Follow up visit recommendation is documented and appropriate[conditional field="Q16" condition="(Q16).is('no')||(Q16).is('uncertain')"]
COMMENT: [text][/conditional]
OVERALL COMMENTS: [text size=100]
OUTPATIENT PROVIDER CHART REVIEW TOOL
<-- Visit Identifier
<-- Visit Date
<-- Visit Provider
<-- Reviewer
<-- Review Date
<-- 1. Patient age
<-- 2. History of present illness is sufficient
<-- 3. Past medical history is documented
<-- 4. Medication reconciliation is documented
<-- 5. Allergies documented
<-- 6. Review of Systems sufficient
<-- 7. Vital Signs are documented and repeated if appropriate
<-- 8. Physical exam sufficient
<-- 9. Abnormal vital signs and/or physical findings addressed
<-- 10. Lab-work and special studies are appropriately ordered
<-- 11. Available Lab-work and special studies are interpreted and documented
<-- 12. Documentation of Informed Consent prior to procedure
<-- 13. Assessment is appropriate and supported by history, exam, and studies
<-- 14. Plan is appropriate
<-- 15. Education documented (disease/treatment/side effects)
<-- 16. Follow up visit recommendation is documented and appropriate
OVERALL COMMENTS:
Result - Copy and paste this output:

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