Association of Professors of Dermatology



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Association of Professors of Dermatology

Chart Documentation Review


Resident: _______________________________ Derm Yr: ________
Evaluator: _______________________________ Date: ___________
Encounter Complexity: Low Moderate High
Diagnosis Summary:__________________________________________________

Focus: Data gathering Exam Assessment Management Quality Care


1
I.1
. Quality of Patient History ( Not observed)

M
IV.51
issing key history elements for basic disease

Identifies key history but misses some associated routine ?s

Accurate targeted hx, but misses some associated complex ?s

Difficult-to-obtain or subtle pertinent information recorded

Identifies appropriate and thorough information in complex disease.

Role models documentation of history

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6

7

8

9

10

Below Expected 1st Yr

Beginning Resident Level

Junior Resident Level

Senior Resident Performance

Ready for Unsupervised Practice

Mastery Level



















2
I.1
. Physical Examination Documentation ( Not observed)

F
IV.51
ailed to perform key exam for routine skin condition.

Performs principal exam but fails to document exam of associated areas. Errors in morphology usage.

Accurate targeted exam. Correctly describes morphology. Pertinent measurements given

Identifies difficult/subtle exam findings. May not clearly convey subtle findings.

Identifies subtle clinical patterns and examines all associated areas.

Role models documentation of examination.

1

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5

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10

Below Expected 1st Yr

Beginning Resident Level

Junior Resident Level

Senior Resident Performance

Ready for Unsupervised Practice

Mastery Level



















3
I.7
. Clinical Judgement ( Not observed)

No differential; Assessment or Plan is way off the mark.

Misinterprets information. Needs guidance for documenting plan. Vague

Appropriate differential. Acceptable plan for common.

Appropriately weighted differential makes excellent plan for common; acceptable plan for complex.

Documents appropriate complex management decisions

Documents alternative diagnostic considerations if current assessment incorrect.

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2

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5

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10

Below Expected 1st Yr

Beginning Resident Level

Junior Resident Level

Senior Resident Performance

Ready for Unsupervised Practice

Mastery Level



















4
I.4
. Therapy Documentation ( Not observed)

No documentation of vehicle, dosage, or frequency of prescribed therapy

Significant errors found in vehicle, dosage, frequency or monitoring of treatment selected.

Minor errors found in vehicle, dosage, quantity, frequency. No documentation of risks or monitoring

Near complete documentation of discussing indications,dosing, risks, expectations of meds. Appropriate med and quantity for issue. Incomplete monitor

Documents discussing indications, dosing, risks, expectations of meds. Appropriate med and quantity for issue.

Includes documentation of planned alternative tx if current plan fails.

1

2

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10

Below Expected 1st Yr

Beginning Resident Level

Junior Resident Level

Senior Resident Performance

Ready for Unsupervised Practice

Mastery Level


















5
I.1


. Organization of Information / Clarity of Documenting Clinical Thought ( Not observed)

T
I.7
horoughly Disorganized note. Rambling; Illegibility

Some sections within note are unclear, disorganized, hard to follow. Syntax or grammar problems

Clear, targeted documentation; Some unclear clinical thought or missing information.

Clear, targeted, precise documentation with pertinent negatives. Clinical thought clear but not always concise

Concise clear note including patient management and targeted, organized plan.

Documents next steps if current plan unsuccessful.

1

2

3

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5

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9

10

Below Expected 1st Yr

Beginning Resident Level

Junior Resident Level

Senior Resident Performance

Ready for Unsupervised Practice

Mastery Level



















6
III.3
. Quality of Care ( Not assessed / not applicable)

Fails to document basic quality of care issues for patients

Basic quality of care practices evident in documentation.

Care is appropriate but opportunities missed to document advanced evidence-based practices

Some evidence-based references included to justify assessment or care plan. Some Documentation tools in place to better ensure care quality

Documentation incorporates basic practices of evidence-based practice/info mastery.

Incorporates advanced structured documentation tools to assist quality of care assessment

1

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10

Below Expected 1st Yr

Beginning Resident Level

Junior Resident Level

Senior Resident Performance

Ready for Unsupervised Practice

Mastery Level



















7
V.3
. Patient-Centered Care ( Not observed)

I
VI.4
nsulting of patient in documentation.

Little evidence in note that patient involved in decision making or plan

Patient consented for plan. Patient education documented for basic interventions

Documents circumstances when stressful encounter with patient. Choices documented

Plan customizes care in context of patient preference and other patient factors. Good longitudinal planning.

Links included to patient education materials

1

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10

Below Expected 1st Yr

Beginning Resident Level

Junior Resident Level

Senior Resident Performance

Ready for Unsupervised Practice

Mastery Level



















8. Overall Clinical Competence ( Not observed)

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10

Below Expected 1st Yr

Beginning Resident Level

Junior Resident Level

Senior Resident Performance

Ready for Unsupervised Practice

Mastery Level



















FEEDBACK AND COMMENTS TO HELP THE RESIDENT IMPROVE PERFORMANCE:

ASSOCIATION OF PROFESSORS OF DERMATOLOGY


Chart Documentation Evaluation Exercise
Instructions:
General principles

  • 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.


Specific instructions

  • 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.

  • 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.


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