North County Health Services

North County Health Services

Pediatric Chart Review Audit- Peer Review

Center: ______Chart Number: ______

Date of Selected Visit: ______Provider: ______Date of Audit: ______

Continuity of Care Yes No NA Comments

·  Referral accomplished

·  Within 1 week ______

·  Consult, diagnostic or hospital records

in chart within 30 days ______

·  All appointments recommended were kept ______

·  NO Show protocol followed ______

·  Emergency phone numbers recorded ______

MEDICAL RECORD REVIEW

·  All pages labeled and dated ______

correct sequence and secure ______

·  Consent for general treatment form signed ______

Financial declaration signed ______

Signed regarding Privacy Notice ______

·  History form on chart by 3rd visit ______

Up To Date History added ______

·  Allergies noted even if NKA ______

Red allergy label on chart if allergic ______

·  Chief complaint properly filled out ______

·  Notes legible, signed and stamped ______

·  Do Not Use abbreviations noted on chart ______

·  MA signature on orders, in red ink ______

·  Progress note header filled out completely ______

·  Pain evaluation completed ______

·  BMI noted ______

·  Full vitals recorded-chief complaint accurate ______

·  Summary sheet completed ______

·  Pediatric physicals accomplished ______

·  Immunization status recorded and copied ______

·  Growth charts present and accurate ______

·  Chronic meds noted and listed ______

·  Health Education noted and checked ______

·  All informed procedure consents signed ______

·  Minor Surgery/Invasive Procedures ______

·  Birth Control Methods ______

·  Financial Screening Blue Sticker (all pts) ______

·  Health Family Sticker (HMO pts only) ______

·  Staying Healthy History Form (HMO only) ______

HOMELESS INFORMATION

·  Are all forms on chart ______

·  Are living arrangements identified ______

·  Health plan appropriate for living conditions ______

·  Referred to homeless case manager ______

Auditor Signature: ______

2/97,6/98,2/01,3/03, 8/03,1/04, 7/04,6/05

Return completed form to Quality Management/Nursing Services Administrator