ASSESSMENT CRITERIA

Assessment Criteria

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