Do you have an upcoming peer review? Are you looking to enhance your patient records?

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Review our tips for improving clinical notes

Physician Assessment & Feedback (PAF) is one of CPSA’s competence programs, designed to provide physicians with support and education. Physicians selected for PAF participate in a virtual practice visit with a CPSA-trained peer assessor, which includes a clinical documentation review and chart-stimulated discussion about clinical reasoning, judgement and management strategy. The goal is to proactively identify opportunities for practice improvements and gain valuable learnings to positively impact patient care.

Based on results from past PAF reviews, we’ve identified some simple steps all physicians can take to improve your clinical documentation and ensure you’re aligned with CPSA’s Patient Record Content standard of practice:

1. Notes on the patient’s main issue should include its duration and severity.
2. The patient history needs both pertinent positives and negatives, especially the presence or absence of red-flag symptoms.
3. Physical exams should be fully documented, focused and include vital signs. Stating “System Exam Normal” is not sufficient.
4. Include a differential diagnosis for each consultation and justify excluding more serious conditions. If diagnosis is known, include it with that encounter (even for prescription refills) and comment if the patient’s condition is stable. If it’s not stable, suggest why not.
5. When starting a patient on a new medication, or changing the dose of an existing medication, inform the patient about possible adverse effects and ensure the conversation is documented.
6. Follow-up appointments should be listed with a clear timeframe (e.g., 3 weeks). Commenting “Follow Up PRN” is not sufficient.
7. Inform the patient and document warning signs and symptoms that should prompt reassessment, along with where the patient should go and how urgently (e.g., call 911 if chest pain).
8. All mental health reviews should include screening for suicidal risk. Use standardized questionnaires GAD 7 for ongoing anxiety and PHQ 9 for ongoing depression.
9. Review cumulative patient profiles at least once a year to update medications and diagnosis.

Use your PAF review or do your own clinical documentation review to complete a PPIP activity!

If you are selected for PAF, or would like to put these tips into practice for your own improvement goals, a clinical documentation review meets the requirements of the CPSA Standard of Practice activity for the Physician Practice Improvement Program (PPIP)!

To complete this review on your own for PPIP, use our online clinical documentation review tool and document an action plan using our template.

Questions about using a clinical documentation review to meet your PPIP requirements? Send an email to PPIP@cpsa.ab.ca.

Questions after being selected for PAF? Please visit our website or email PAF@cpsa.ab.ca.