Policy 180-04 Attachment 6

CONFIDENTIAL/Peer Review UC Davis Student Health and Counseling Services

Provider Electronic Health Record (EHR) Chart Review

PSYCHIATRISTS:

Provider Being Reviewed: Academic Year: FY Date of Review: Page 1 of 1

INSTRUCTIONS: Please review each EHR section and select 1, 2, 3 or NA (1=adequate 2=Standard of Care Met with Opportunities for Improvement Identified, 3=Deviation from Standard of Care; NA=Not applicable). As you complete the review, please keep in mind that opportunities for improvement can include communication issues, educational issues, systems or processes that may need improvement, as well as patient care issues. Rating scores of ‘3’ will be referred for Special Case Review process (See Policy 180-04). Please provide comments when rating ‘2’ or ‘3’; and initial all reviews. Positive comments are also welcomed. Copies will be provided to reviewed clinicians.

SID Number:
(Intake and follow-up visits reviewed) Date of Service:
Diagnosis Randomly Selected Diagnosis/Chief Complaint:
VISITS/NOTES: / Use 1, 2, 3 or N/A for each / Use 1, 2, 3 or N/A for each / Use 1, 2, 3 or N/A for each / Use 1, 2, 3 or N/A for each / Use 1, 2, 3 or N/A for each
History is adequate
Diagnosis appropriate and fits with the treatment plan?
Does the information on the evaluation support the diagnosis?
Side effects addressed?
Consultations and referrals; appropriate and timely?
Symptomatic Improvements documented?
RESULTS: Lab tests ordered appropriately, followed-up, and communicated with patient?
DOCUMENTS: Scanned documents from other facilities reviewed (if applicable)?
MESSAGES: Advice/communication in reference to this DOS: Timely/appropriate?
Medications List: complete and accurate?
Problem List: PLEASE REVIEW & COMMENT – no score of 1 or 2 is necessary
Compliance to Practice Guidelines and/or
NP Standardized Procedures and Protocols
*OVERALL RANKING of Care (1 , 2 or 3) / 1 2 3 Reviewer’s Initials / 1 2 3 Reviewer’s Initials / 1 2 3 Reviewer’s Initials / 1 2 3 Reviewer’s Initials / 1 2 3 Reviewer’s Initials
Comments (Please continue your comments on the reverse side if needed):
Assigned Reviewer:

06/2015 kkf (1=adequate 2=Standard of Care Met with Opportunities for Improvement Identified, 3=Deviation from Standard of Care; NA=Not applicable