General & Administrative
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Scribe Chart Audit Tool
[text name="variable_1"] <-- Scribe
[date name="variable_2"] <-- Visit Date
[text name="variable_3"] <-- Visit Provider
[text name="variable_4"] <-- Reviewer
[text name="variable_5"] <-- MR
[comment memo="Answer 'yes' if Category is sufficient, 'no' if insufficient, PC = provider charted or N/A and follow with specific comments as needed"]
[select name="variable_6" value="yes|no|pc|N/A"] <-- 1. Scribe Attestation[conditional field="variable_6" condition="(variable_6).is('no')"]
COMMENT: [text][/conditional]
[select name="variable_7" value="yes|no|pc|N/A"] <-- 2. HPI [comment memo="4 elements, good flow?"][conditional field="variable_7" condition="(variable_7).is('no')"]
COMMENT: [textarea][/conditional]
[select name="variable_8" value="yes|no|pc|N/A"] <-- 3. PMSHx [comment memo="at least 2/3"][conditional field="variable_8" condition="(variable_8).is('no')"]
COMMENT: [textarea][/conditional]
[select name="variable_9" value="yes|no|pc|N/A"] <-- 4. ROS [comment memo="no contradictions, 10+ box checked?"][conditional field="variable_9" condition="(variable_9).is('no')"]
COMMENT: [textarea][/conditional]
[select name="variable_10" value="yes|no|pc|N/A"] <-- 5. Physical Exam [comment memo="no contradictions, correct system?"][conditional field="variable_10" condition="(variable_10).is('no')"]
COMMENT: [textarea][/conditional]
[select name="variable_11" value="yes|no|pc|N/A"] <-- 6. Pulse Ox[conditional field="variable_11" condition="(variable_11).is('no')"]
COMMENT: [text][/conditional]
[select name="variable_12" value="yes|no|pc|N/A"] <-- 7. EKG [comment memo="time, 3+ findings"][conditional field="variable_12" condition="(variable_12).is('no')"]
COMMENT: [text][/conditional]
[select name="variable_13" value="yes|no|pc|N/A"] <-- 8. Radiology [comment memo="3+ findings, attestation"][conditional field="variable_13" condition="(variable_13).is('no')"]
COMMENT: [text][/conditional]
[select name="variable_14" value="yes|no|pc|N/A"] <-- 9. MDM [conditional field="variable_14" condition="(variable_14).is('no')||(variable_14).is('pc')"]
COMMENT: [textarea][/conditional]
[select name="variable_15" value="yes|no|pc|N/A"] <-- 10. Procedures [conditional field="variable_15" condition="(variable_15).is('no')||(variable_15).is('pc')"]
COMMENT: [text][/conditional]
[select name="variable_16" value="yes|no|pc|N/A"] <-- 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('pc')"]
COMMENT: [text][/conditional]
[select name="variable_17" value="yes|no|pc|N/A"] <-- 12. Discharge instructions[conditional field="variable_17" condition="(variable_17).is('no')||(variable_17).is('pc')"]
COMMENT: [text][/conditional]
[select name="variable_18" value="yes|no|pc|N/A"] <-- 13. Grammar and punctuation [conditional field="variable_18" condition="(variable_18).is('no')"]
COMMENT: [textarea][/conditional]
[select name="variable_19" value="yes|no|pc|N/A"] <-- 14. Spelling [conditional field="variable_19" condition="(variable_19).is('no')"]
COMMENT: [textarea][/conditional]
[select name="variable_20" value="yes|no|pc|N/A"] <-- 15. Cohesive chart? [comment memo="no contradictions, reads well?"] [conditional field="variable_20" condition="(variable_20).is('no')"]
COMMENT: [textarea][/conditional]
OVERALL COMMENTS: [textarea name=variable_21]
Scribe Chart Audit Tool
<-- Scribe
<-- Visit Date
<-- Visit Provider
<-- Reviewer
<-- MR
Answer 'yes' if Category is sufficient, 'no' if insufficient, PC = provider charted or N/A and follow with specific comments as needed
<-- 1. Scribe Attestation
<-- 2. HPI 4 elements, good flow?
<-- 3. PMSHx at least 2/3
<-- 4. ROS no contradictions, 10+ box checked?
<-- 5. Physical Exam no contradictions, correct system?
<-- 6. Pulse Ox
<-- 7. EKG time, 3+ findings
<-- 8. Radiology 3+ findings, attestation
<-- 9. MDM
<-- 10. Procedures
<-- 11. Reassessment of patient’s condition after treatment interventions (e.g. nebs/pain/etc)
<-- 12. Discharge instructions
<-- 13. Grammar and punctuation
<-- 14. Spelling
<-- 15. Cohesive chart? no contradictions, reads well?
OVERALL COMMENTS:
Result - Copy and paste this output: