Chart Documentation Evaluation Exercise Instructions:
This tool is designed to help assess the chart documentation and written communication skills of dermatology residents. It is appropriate for encounters in an outpatient or inpatient clinical setting. The evaluation can include assessment of procedure notes as well as clinical notes that do not involve procedures. This tool is appropriate to evaluate both New and Established patient notes.
All or part of an encounter note can be observed. It is not required to assess the entire document, although the tool was designed to provide feedback from the assessment of the entire clinical note.
Notes for assessment can be selected at random or can be targeted for degree of complexity. That decision is made by the faculty member selecting the charts for assessment.
Not every document will have quality measures assessable.
Provide direct, specific constructive feedback to the trainee after the encounter. Determine what are ‘must’ areas for improvement vs. ‘the art of how I would have done it’ areas for improvement (ie, corrections vs. advice).
If a hard copy of the document is printed as part of the review, it is appropriate and possibly more clear to the learner to make some feedback notes directly on this document printout as opposed to referring to the issues on the evaluation form.
If a hard copy of the document is created, care must be taken to remain HIPPA compliant.
Encounter complexity – Determined by the evaluator. Factors to consider include the diagnosis, clinical situation, patient interactions.
For example, a visit for a routine skin cancer check in a patient with a history of basal cell carcinoma with nothing new to see but a well-healed scar is likely low complexity. A visit for a routine skin cancer check in a patient with signs of recurrent skin cancer might be of moderate complexity. A visit for routine skin cancer check in a patient upset by the resulting scar made by a previous resident colleague could be moderate or high complexity.
Diagnosis / summary – Describe the diagnosis and / or what occurred.
Ex: Suspect allergic contact hand dermatitis, discuss patch testing
Focus – Check the focus or foci that are assessed. Several foci may be checked if several parts of the note were assessed (typical).
Skills – Rate the trainee on the milestones scale for each skill. It is important to remember that trainees are not being compared relative to other trainees; they are being rated on a continuum; on a scale designed to assess progression of skills from novice to master. It is common for first year residents to score 3 or 4 out of 10 and still be great first year residents.
If a particular written component is not reviewed, check the “Not observed” box.
Feedback and comments – Note specific positives in the encounter and give constructive feedback on how the trainee could improve.