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Date of Report:
04/2007
Source:
Florida/Caribbean AETC
The Florida/Caribbean AETC (F/C AETC) frequently utilizes chart reviews as a needs assessment for targeted training and technical assistance activities. While reviewing medical records at various clinics in their region, F/C AETC clinical faculty identified the need for tools to better organize and summarize large amounts of critical medical information for HIV-infected individuals. For example, F/C AETC clinical faculty found that clinicians documented information regarding medications and vaccinations multiple times in the progress notes rather than once in a designated space for this type of information. Procedures may be repeated unnecessarily only because information is not carried forward in an organized fashion. There is also a potential cost savings to be realized with better medical chart organization.
To address this need, F/C AETC developed a user-friendly and adaptable set of chart forms and flow sheets, with instructions. The goal of these charting tools is to improve quality and efficiency of care by organizing and summarizing medical information in a manner that reduces the time a clinician needs to prepare for a visit or respond to an emergency. The following chart forms and flow sheets are included in this set:
- Screening/Immunization/ARV Cumulative Summary
- Immunology and Ongoing Screening Lab Flow Sheet
- Treatment and Monitoring Flow Sheet
- Medication Sheet
- Controlled Substance Sheet
- Problem List
- X-Ray and Procedure Log
In addition to developing these forms and flow sheets, F/C AETC faculty worked directly with clinic administrators to address barriers to implementation. Such barriers include cumbersome approval processes. Through collaborative planning between the AETC faculty and clinic administrators, many clinics were able to overcome barriers and implement the charting forms as part of plan- do- study- act (PDSA) quality improvement initiatives.
To download this charting form set, as well as other charting tools, visit the F/C AETC website at
www.faetc.org/resources
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