Licensed Clinician Chart Review

Licensed Clinician Chart Review

Clinician / Date of Review
Supervisor
Name of Patient / DOB / DOS / Routine Visits / Non Routine Visits / Comments

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

/ C=Compliant NC=Noncompliant NA=Not applicable

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

Name of Patient / DOB / DOS / Routine Visits / Non Routine Visits / Comments

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

/ C=Compliant NC=Noncompliant NA=Not applicable

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

Name of Patient / DOB / DOS / Routine Visits / Non Routine Visits / Comments

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

/ C=Compliant NC=Noncompliant NA=Not applicable

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

Name of Patient / DOB / DOS / Routine Visits / Non Routine Visits / Comments

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

/ C=Compliant NC=Noncompliant NA=Not applicable

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

1. History (initial visit) ____
2. Physical (initial visit) ____
3. Lab work as indicated ____
4. Vital signs/baseline info ____
5. Problem list up to date ____
6. Assessment clear? ____
7. Plan Appropriate? ____
8. Return visit indicated? ____
9. Prescriptions indicated? ____
10. Physician consult ____

/

1. Chief complaint ____
2. Relevant history ____
3. Physical exam ____
4. Vital signs, baseline data ____
5. Lab work as indicated ____
6. Diagnosis/Assessment _____
7. Prescriptions _____
8. Patient education _____
9. Return or follow up _____
10. Consults _____

Licensed Clinician Chart Review

Signature Page

Clinician / Date of Review
Supervisor
Comments