PPIP Activity Clinical Documentation Review

CPSA standard of practice reviewed: Patient Record Content - College of Physicians & Surgeons of Alberta | CPSA

Opportunity or gap: assessment of quality of clinical documentation at the clinic.

Goal: improve standard of clinical documentation.

Procedure

1)  Use checklist below and examine 5 patient encounters from different charts.

2)  See how many of the features on the checklist are missing in your own charts.

3)  Look for any patterns and common things you are not including in your notes.

4)  Use the template link to develop an action plan to improve your clinical documentation   PPIP-Action-Plan-Template.pdf

Examine 5 patient encounters from different charts.