Atch 2b OPPE Monthly.pdf

Provider Reviewed Name Name Name Name Name Patient Name

Patient SSN

Date of Visit

SUBJECTIVE

Adequate documentation of chief complaint/purpose for visit and history of present illness

2 Adequate documentation of review of systems

OBJECTIVE

Pertinent personal medical hx, social/psychosocial hx, and/or family medical hx documented

4 Evidence of review of allergies/drug sensitivities

Evidence showing review of VA-prescribed and non-VA prescribed medications, OTC medications, herbs, and supplements

Adequate documentation of neurological exam as pertinent to chief complaint and history of present illness

Results of available diagnostic studies (e.g. labs, radiographs, microbiology, pathology) documented and managed

ASSESSMENT

8 Assessment(s)/finding(s)/impression(s) clearly documented

10 Assessment addressed chief complaint and history of present illness

PLAN

Overall orders (medication changes, consults, tests, etc.) consistent with plan of care clearly documented

Follow-up plan (e.g. disposition, discharge, handoff, return to clinic (RTC)) appropriate for the patient's condition

12 Education/counseling regarding care provided to patient and/or family

DOCUMENTATION

13 Authentication date, time, provider signature were within 24 hours of encounter

Pertinent diagnoses for current encounter and the active problem list only consist of ICD-10 diagnoses pertinent to specialty

15 No unnecessary diagnostic results copied verbatim in document

Additional Specialty Expectations

16 Appropriate subsequent orders on follow up of the results of diagnostic studies

17 Inpatient consults seen within 24 hours

OVERALL RATING

18 Please indicate rating (1, 2, or 3) of the overall documentation and care

(1) Satisfactory

(2) Some minor deficiencies, needs improvement

(3) Unsatisfactory

OVERALL COMMENT(S) (to include any concerns and give examples):

ROBERT J DOLE VA MEDICAL CENTER

OPPE MONTHLY CORE COMPETENCY

NEUROLOGY

HOW TO COMPLETE THE REVIEW

Open excel worksheet and save it under a different name with adding your name to the end of the provided file name. Make sure to click on “Enable Content” if it is not.

Click on the box corresponding to the statement of the reviewed record and click the drop down arrow to select "Yes," "No," or "X-N/A" for each statement or as per drop down options.

The red flag are comments for you with the given statement.

After you have completed these five records, right click on the signature line , scroll to "sign" to sign your work.

You will have ten business days to finish the five reviews and return back to AO.