Get Clinical Record Worksheetdoc - Dhmh Maryland

This guide provides a comprehensive overview of how to accurately fill out the Clinical Record Worksheet for the Maryland Board of Examiners in Optometry. Following these detailed steps will ensure that your documentation meets the required standards effectively.

Follow the steps to complete the Clinical Record Worksheet online.

1. Press the ‘Get Form’ button to access the Clinical Record Worksheet and open it in a suitable editor.
2. Begin by entering the optometrist’s name and license number in the designated fields. Ensure that this information is accurate and up to date.
3. Next, input the peer reviewer’s name and the date of the review. This step is essential for maintaining a record of who conducted the review and when.
4. For each checklist item, mark the appropriate box—either 'Adequate' or 'Inadequate'—based on the assessment of the clinical record. If a particular item does not apply, select 'Not applicable'.
5. Evaluate and check the legibility of the record, ensuring that all written records are clear and understandable.
6. Confirm whether the record follows the S.O.A.P. format clearly by reviewing each section of the chart to ensure proper documentation.
7. Assess if the history and symptoms are recorded, making sure the chief complaint is evident and documented clearly within the chart.
8. Document significant illnesses, medical conditions, and current medications, ensuring comprehensive history-taking.
9. Clearly record any allergies and drug sensitivities in a prominent location within the record for easy reference.
10. Review and ensure that visual acuities, pupillary testing, tonometry, and biomicroscopic findings are documented accurately.
11. Validate the diagnoses listed in the record to ensure they are consistent with the recorded history and examination findings.
12. Review the treatment plan and choice of drugs, ensuring they align with the established diagnoses.
13. Confirm that appropriate follow-up care is outlined as part of the treatment plan.
14. Check subsequent visits for evidence of appropriate care as documented in follow-up records.
15. Ensure that any consultations and referrals made are documented clearly and are timely.
16. Finally, make sure all entries are initialed or signed by the optometrist to validate the record.
17. After completing the assessment, you can save changes, download, print, or share the form as needed.

Take the next step toward efficient documentation by completing your Clinical Record Worksheet online.