Name: Date:

*Using USPSTF/ADIP Recommendations

Criteria	yes	no	N/A (comments)
There is sufficient information at the top of note to identify patient
Note is dated /Clinic and type of visit recorded (ex. “AIM follow up”)
chief complaint recorded
HPI is logical, chronologic, pertinent review questions are included
ROS is noted on each visit- positives reported in adequate detail, no repetition of HPI. Screening for mood disorder and domestic violence is included on initial evaluation
Pain assessment is recorded with the use of pain scale. Pain assessment should be performed at the initial visit, and reassessment should be performed to follow up past complaints.
Social History obtained, including substance screening, living situation
Family History
A Problem List is started by the second visit (problem list is “weeded” at f/u visits)
Problem List include significant diagnosis and procedures, and excludes info that can be moved to Past Med. Hx
Drug allergies recorded on every note
Medication list updated on each visit using medication bottles, and not cut and pasted unchanged
Physical exams recorded, and includes complaint pertinent maneuvers
Pertinent labs/Xrays reviewed, interpreted, and not indiscriminately pasted in en bulk
Assessment included appropriate differential diagnosis, this should include the “do not miss” diagnosis and the most likely dx
Chief complaint is addressed as problem #1 in A/P (don’t forget the pt’s agenda)
Historical and exam findings are cited to support final diagnosis
Reassessment and follow up of chronic problems is recorded
Plan is recorded, explanation for each testing, consult, rx is provided
Assessment and plan is thoughtful, accurate, concise, and complete
Note is readable, concise, thoughtful, and does not resemble in bulk the note from the prior visit
Health Maintenance
Life Style Modification Education – diet, substance use, exercise, safety, CAD risk factors, sexual history. Counseling and teaching documented.
Vaccination –Influenza, pneumovacs for appropriate patients
Vaccination (others -Td, PPD, MMR, Hep B, HPV, zoster)*
Tobacco counseling documented for active smokers at each clinic visit
Nutrition, wt, Diet reviewed, counseling documented yearly
Has the patient been screened for depression
Cholesterol screening*
Mammography
Pap smear/GYN exam*
Bone Density *
Colon CA screening*
If diabetic-yrly a1c, LDL, microalb, ophtho exam, foot check