PIEDMONT ACCESS TO HEALTH SERVICES, INC.

Policy Number: 01-09-006

SUBJECT:Peer Review

EFFECTIVE DATE: 08/06/2009

REVIEW/REVISED:03/31/2010, 03/17/2011, 04/10/2012, 09/17/2012, 05/30/2013, 07/03/2014, 08/11/2015,

12/01/2015, 06/23/2016

POLICY:

It is the policy of PATHS Community Medical Centers to conduct quarterly medical chart reviews following established guidelines.

PURPOSE:

To assess and identify areas for improvement in the provision of medical care, utilization, continuity of care, documentation in the medical records and adherence to established practice guidelines and standards of care. To promote performance improvement, patient safety and reduce risk.

PERSONNEL: Chief Medical Officer, Chief Clinical Officer, Providers, Chief Human Resources Officer

PROCEDURE:

  1. Five randomly chosenmedical records shall be reviewed for each medical provider.
  2. Charts will be selected randomly using Research Randomizer software.
  3. Medical chart reviews shall be completedquarterly.
  4. Reviewers shall be assigned by the Chief Clinical Officer based the following criteria:
  • All reviewers shall be providers at one of PATHS Community Medical Centers.
  • Reviewers will review medical records of peers.

5 charts and worksheets will be given to each provider quarterly and assigned randomly to a peer.

  1. All review findings will be forwarded to the PATHS Chief Medical Officer and Chief Clinical Officer.
  2. The Chief Clinical Officer will review and summarize findings for each individual provider as well as the group as a whole. Individual provider summaries, which will be free of any patient information, will be given to the Chief Human Resources Officer to be kept in the providers confidential employment file and used along with any performance improvement information at the time of renewal or revision of privileges.
  3. The Chief Clinical Officer will present aggregate data quarterly to the PATHSContinuous Quality Improvement Committee and the Board of Directors.
  4. Chart reviews shall focus on the following areas (Specific criteria listed below).
  • Documentation
  • Continuity of Care
  • Preventive Care and Counseling
  • Patient Safety and Risk Management

Medical Chart Review

Criteria / Definition
  1. Reason for visit /chief complaint clearly documented
/
  • The reason for each encounter is clearly documented

  1. Objective findings/clinical assessment is documented
/
  • Objective findings/clinical assessment and physical exam are documented and correspond to the patient’s chief complaint, purpose for seeking care and/or ongoing care for chronic illnesses

  1. Working diagnoses are documented and consistent with findings
/
  • Working diagnoses that logically follow from the clinical assessment and physical exam are documented
  • Documentation of chronic conditions is in accordance with established Clinical Practice Guidelines.

  1. Plan of action/treatment is documented and consistent with diagnosis(es)
/
  • Proposed treatment plans, therapies or other regimes are documented and logically follow previously documented diagnoses
  • Rationale for treatment decisions appear medically appropriate and are substantiated by documentation in the medical record.
  • Laboratory and other studies are ordered as appropriate, including tests relating to chronic illnesses (DM, HTN) as indicated by practice guidelines.

  1. Social, surgical, family history completed
/
  • Information is entered correctly and is up to date
  • Family history is entered as structured data

  1. Unresolved problems from previous visits are addressed in subsequent visits.
/
  • Continuity of care from one visit to the next is demonstrated when follow-up of unresolved problems from previous visits is documented in subsequent visit notes.

  1. Follow-up Instructions are documented
/
  • Specific follow-up instructions should be documented (PRN or as needed acceptable)

  1. Consultation reports, lab and diagnostic test results reflect provider review
/
  • All are signified as reviewed by the ordering or covering provider
  • Abnormal reports, tests have notation of follow-up

  1. QA measures for chronic conditions are completed if applicable.
/
  • For DM: 2 HbA1c per year, retinal exam yearly, flu vaccine, ACE/ARB/ASA use, Mic/Alb ratio every year, foot exam yearly, SM goal yearly.
  • For HTN: Last BP <140/90
  • Asthma: Intermittent or persistent?
Appropriate pharmacologic therapy?
  1. Patient non-compliance or refusal is addressed by the provider
/
  • Non-compliance is documented and is periodically addressed indicating risk and benefits have been explained.

  1. Preventive Screening and services are offered in accordance with medical practice guidelines and best practices
/
  • Services such as colonoscopy, cervical cancer screening, mammography, vaccines were ordered
  • If the patient chose to defer or refused the service, there is clear documentation of the deferral or refusal.

  1. Diet/exercise/lifestyle
/
  • Documentation of counselingand follow-up for adult patients (18 and older) with BMI >25 or less than18.5is noted.
  • Children and Adolescent (3-17): diet and physical activity counseling with patient and/or parent/guardian is noted, regardless of pt. weight.
  • Smoking Cessation counseling is noted

  1. Pediatric Immunizations
/
  • Appropriate immunizations in accordance with AAP and CDC are current. If not current, documentation is present that attempts were made to contact parent.
  • Documentation of refusal by parent.

SIGNATURES:

______

Chief Executive OfficerDate

______

Chief Medical OfficerDate

______

Chief Clinical OfficerDate

______

Board ChairDate

Provider:______Physician/NP/PA Reviewer:______

Date:______

Key: X = Meets Criteria/ StandardO = Does Not MeetN/A = Not Applicable for this Case

Account # / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / New
pt / 11 / 12 / 13 / 14 / Comments / Visit Date

ALL CHARTS:NEW PATIENTS –Abstract MR info:

1. Chief Complaint & HPI documented11. Medication and allergies

2. Relevant social/family history critical to diagnosis is documented12. PMH

3. Pertinent ROS documented13. Social Hx & Habits

4. Physical Findings documented14. Family Hx

5. Appropriate diagnostic test ordered

6. Treatment rendered and f/u care instructions noted &

appropriate to impression

7. Procedures noted

8. Diagnostic impressions noted

9. Medication List updated

10. Problem List updated

11. Preventative Care ordered/documented

1