• Membership Info
• Resources
• Member Engagement
• Council Elections
• Peer Assessment
  • Selection for Assessment
  • What is a Peer?
  • The Assessment
  • Preparing for a Peer Assessment
• Out-of-Hospital Premises Inspection Program

Table of Contents

The Assessment

Medical Records

Reviewing a physician’s medical record-keeping system is perhaps most often associated with peer assessment. A records review enables an assessor to develop a picture of the physician’s practice and an understanding of his/her approach to patient care.

Many of the components of the medical record reviewed during a peer assessment are required by regulation, while others have been shown to be extremely useful in systematically recording information that is necessary for quality patient care. For example, there is no legal requirement for office-based physicians to maintain cumulative patient profiles (patient summary sheets), but through experience the Quality Assurance Committee has found them to be helpful to physicians.

The art of record keeping and the increased recognition of its importance have led to the design of various medical record templates and forms. The medical record must be functional to the user and these templates and forms can assist greatly in this regard. For example, the SOAP format of record keeping can assist a physician in ensuring that s/he has thoroughly reviewed a presenting problem and developed a plan of medical management. Flow sheets, such as those for monitoring blood sugar levels in diabetic patients, or INRs in patients on anticoagulants provide the physician with quick information about the need to modify a patient’s medical care.

To review the legally required medical-record keeping components, as well as the other components of good record-keeping, access the College’s Medical Records policy on-line.

Record-keeping protocols developed by the program are also available online:

• Record-Keeping and Patient Management Tools 
• Required Medical Record Components 
• Required Electronic Medical Record Components

Quality of Patient Care

While assessors can glean some insight into patient management through a record review, the assessment is not complete without an opportunity for discussion between the assessor and the physician. This discussion generally takes from 20 to 60 minutes following the assessor’s review of the records.

Through the records review and discussion with the physician, assessors try to put together the “story of the patient”. An assessor evaluates the physician’s ability to take adequate histories, conduct appropriate examinations, order the necessary diagnostic tests, identify the appropriate course of action, conduct the necessary interventions, and monitor patients, as necessary.

While the types of patients seen and the problems they present will vary between specialties, there are commonalities to good patient care. The program has identified that patient care can be broken down into components based on the types of patient encounters.

Peer Assessment Clinical Protocols

• New Presentations/Acute Condition Management
• Management of Patients with Ongoing/Chronic Conditions
• Health Maintenance
• Psychosocial Care
• Continuity of Care and Referrals
• New Consultations and Pre-operative Management
• Operative Patient Management and Procedures
• Post-operative Management and Follow-up
• Practice Assessment Report – Anesthesia
• Practice Assessment Report – Pathology
• Practice Assessment Report – Long-Term Care
• Practice Assessment Report – Emergency Medicine Management

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