CDS15 Ship Visit and QAOVERALL PEERREVIEW : ______
Name of IDC Being Reviewed: Command: Date of Visit: Month Being Reviewed:
Grading Scheme: OVERALL PT SCORE WILL BE EITHER SAT or UNSAT ONLY
MEDICAL ENCOUNTERS
/ 1 / 2 / 3 / 4 / 5 / 6 /COMMENTS
Last initial, Last 4 / 1. CCDiagnosis:Date of medical note
Note signed w/in 72 hrs of initial encounter
Administrative Items Sat?
(Name/SSN/Rank/Rate/Date/Signed)
Subjective Items / ------/ ------/ ------/ ------/ ------/ ------
HPI / 2. CC & Diagnosis:
Focused ROS
PMHx
Meds noted
Allergies noted
FMHx / 3. CC & Diagnosis:
PSGHx
SCHx
+/- Sexual Hx, If ♀, GYN Hx/LMP/GxPx
Obecjtive Items / ------/ ------/ ------/ ------/ ------/ ------
Vital Signs performed
CV Exam
Pulm Exam / 4. CC & Diagnosis:
Abd Exam
Focused PE
Asessment and Plan / ------/ ------/ ------/ ------/ ------/ ------
Written Differential (>2 min.)
Initial Assessment/Dx appropriate / 5 CC & Diagnosis:
Treatment plan appropriate
Specific Follow-up plan documented
Follow up note, if appropriate
Vital signs addressed ifabnl / 6. CC & Diagnosis:
Use of meds/antibiotics appropriate
Counseledpt about med SE & documented
Lab/X-ray results noted if ordered
U-HCG performed, results documented
If consult ordered, has appt been scheduled?
OVERALL PT SCORE (SAT or UNSAT)
Monthly Metric Data (IDC to provide data)
# of Patients In Sick Call Log: ______
CME’s obtained this month/total for year: _____/15 / Underway Schedule:
This month
Next month
The next month / Recommended Scoring Scheme (based on overall grade for each pt encounter):
6 patients
5 or 6 SAT pt encounters = SAT
4 SAT pt encounters = MARGINAL SAT
0 or1 or 2 or 3 SAT pt encounters = UNSAT
5 patients
4 or 5 SATpt encounters = SAT
3 SAT pt encounters = MARGINAL SAT
0 or 1 or 2 SAT pt encounters = UNSAT
4 patients
4 SATpt encounters = SAT
3 SAT pt encounters = MARGINAL SAT
0 or 1 or 2 SAT pt encounters = UNSAT
APP A Expiration Date ______Reviewed sections of Appendix A: Signed Appendix B if applicable:
______NEXT VISIT: ______
Physician Supervisor SignatureIDC Signature