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Clinical Measures Chart Review Process

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Clinical Measures

Chart Review Process

Clinical Measures

• Chart Review

• Data Collection

• Report on performance• vs peers

• Program as a whole

• Advisors- feedback

• PD, semiannual evals

• CCC

Chart Review Tool

• Reviewed: Resident who signed H&P document

• Exclude H&P notes from Attendings or ARNPs only!

• GBS problem (pos or unknown) addressed in Problem List/Plan

• The metrics:

Weight Length and HC

• Hypoglycemia protocol addressed in Problem List

NICU charts

CERNER

• Hosp Discharges

• Asthma Powerplan

LIST of D/C is made available to reviewer

Proxy access to the list is granted…

Proxy process

Asthma Powerplan

• List of charts will be provided

Correct/Wrong Albuterol MDI dose ordered?

• An example of incorrect dose ordered for patient…