1. Quality of Care

• Documented investigation appropriate to patient’s complaint/condition
• Appropriate diagnoses are reached
• Management plan and medication prescribed are appropriate to condition being treated
• Indications for surgical and other procedures are documented and appropriate
• Adequacy of treatment of both acute and chronic conditions
• Counselling and psychotherapeutic sessions are appropriately indicated
• Utilization of support and community resources
• Practice guidelines are being followed
• Evidence of appropriate investigations and follow-up of results
• Assessment of lifestyle and preventive health issues
• Arrangements are made for the physician’s patients to be cared for in his/her absence
• Emergency problems are dealt with promptly and effectively

2. Medical Records

• Adequate notes for reader to follow present management
• Stress quality of legibility
• Patient identity is clearly evident on each chart component
• Describe organization within charts, retrieval of items
• Use of standard forms (cumulative patient profile, flow sheets, medications, history summary, etc.)
• S.O.A.P. type or narrative notes covering all areas
• Diagnosis and treatment plan are clearly stated
• Allergies and drug reactions clearly documented, as well as dates of immunizations
• Documentation of medications – type, duration, evidence of regular review
• Significant positive and negative findings are recorded
• System for acknowledgement and follow-up of abnormal test results
• Retention of pathology reports, hospital discharge summaries, operative notes, etc.
• Use of pediatric growth charts and Saskatchewan Prenatal Forms
• Documented evidence that periodic general assessments are performed
• Documented evidence that lifestyle and health maintenance issues are discussed
• Identification of physicians making chart entries
• Evidence of progress notes for management of chronic conditions
• Recording in charts of significant telephone advice given

3. Physical Facilities and Practice Organization

A. GENERAL OFFICE FACILITIES

• Adequacy of total area – describe size, design, atmosphere, cleanliness, maintenance
• Accessibility – wheelchair, parking, etc.
• Waiting rooms – comfort, current reference and reading materials, toys
• Examining rooms – adequate size and equipment, private
• Washrooms – accessibility, cleanliness

B. TELEPHONE SYSTEM

• Number of incoming lines and available staff for answering
• Are fax, e-mail services available
• Scheduled call back time or other means of returning calls
• System to ensure incoming messages are appropriate directed and acknowledged
• Physician’s contactability during office hours as well as after hours on-call system

C. APPOINTMENT SYSTEM

• Does it satisfactorily accommodate patients
• Booking rate (patients per hour) for new or full assessments
• Booking rate (patients per hour) for repeat patients
• Waiting time for appointments, waiting time in waiting room
• Does physician keep to appointment schedule
• System for urgent or emergency appointments
• Is a Day Sheet maintained – manual or computerized
• Mechanism to ensure patients are not missed in the waiting room

D. FILING SYSTEM

• Chart types – family or individual

Electronic Medical Records

E. MEDICAL INSTRUMENTS AND EQUIPMENT

• Ensure equipment, including minor surgical materials, is appropriate to the type of practice
• Appropriate sterilization procedures in place
• System for managing biomedical waste and medication disposal

F. DRUG SUPPLIES AND SAMPLES

• Ensuring appropriate drugs are available and appropriately stored
• Maintaining current list of drugs on hand, monitoring expiration dates
• Narcotic/controlled drug security

G. EMERGENCY FACILITIES

• Emergency tray/cart – appropriately stocked, centrally stored, readily available
• Availability of Adrenalin and appropriate syringes for administration
• Presence of 9-1-1 service in community or alternate emergency personnel
• List of minimal drugs and supplies in the clinic, monitoring of expiration dates
• Knowledge of office staff in the event of an emergency of disaster

H. LABORATORY INVESTIGATIONS

• Type of investigations available
• Are they accessible on-site or close by

I. PERSONNEL

• Number of staff persons, duties and training
• Documented plans in place for handling emergencies in the office
• Regular staff meetings/communications
• Documented job descriptions and office policies

J. WALK-IN CLINICS

• Determine whether physician provides ongoing or episodic care
• Evidence of patient education regarding importance of regular visits to their family physician
• Determine patients’ family physician and document information in charts
• Mechanism for provision of information to patients’ family physician
• System for handling non-urgent referrals
• Provision for after hours coverage

Establishment of clinic policies and standards for employed physicians

K. MISCELLANEOUS OBSERVATIONS

• System for handling telephone requests for repeat prescriptions from patient or pharmacy
• System for handling incoming reports, test results
• System for handling consultations and referrals
• Policy in place when a patient is dressing/undressing, is appropriate draping provided
• Accessibility of reference materials for physicians and patients – hardcopy, electronic

L. HEALTH INFORMATION PROTECTOIN ACT COMPLIANCE (HIPA)

• Posters/brochures posted in clinics re privacy / patient confidentiality
• Appointment of a privacy officer to deal with issues relating to patient confidentiality and HIPA
• Security of patient records clinic
• Staff and signed confidentiality agreements