1. No category

Affiliated Care Practitioner Site Review Tool
Practitioner/Group:
Address:
MD in charge:
Contact Person & Title:
Phone:
Fax:
PCP
High Volume
specialty:
OB/GYN
Names of other practitioners in the practice:
1.
2.
3.
4.
5.
6.
Initial visit
Date:
Biennial visit
Date:
Summary:
Recommendations:
acceptable
unacceptable
Site reviewers:
Chart reviewers:
Facility Representative Signature:
Date:
Practitioner Site Review Tool
I. PHYSICAL ACCESSIBILITY
A. General Accessibility
Yes
No
Yes
No
Physician’s office easily seen from street
comments:
Office name clearly visible
comments:
Access into office unimpeded
comments:
Adequate parking
easy to find parking on street
spaces available in parking lot
available at peak times
comments:
B. Wheel Chair and Disabled Accessibility
Wheel chairs have easy access to office
wheel chair access curb
door into clinic easy to open from
wheel chair
parking is near clinic/street
parking spaces for disabled identified
if not, and it is a small clinic,
parking is readily available
comments:
Wheel chair accessible bathroom meeting
ADA standards
bathroom has rails
bathroom door wide enough
comments:
Wheel chair accessible exam room(s)
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Practitioner Site Review Tool
doorway to exam room wide enough
absence of equipment or other
obstruction in hallway inhibiting wheel
chair access
comments:
Elevator operable from wheel chair
elevator large enough to accommodate
wheel chair
elevator control panel easily accessible
from wheel chair
comments:
II. PHYSICAL APPEARANCE
Yes
Exterior appearance of physician’s office
indicates routine maintenance
clean sidewalks
grounds free of litter
comments:
Interior appearance of the office is neat
floors recently washed
bathrooms recently cleaned
office is clean
empty wastebaskets
absence of clutter
comments:
Reviewer would feel comfortable with
receiving care in this office
comments:
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No
Practitioner Site Review Tool
III. ADEQUACY OF WAITING AND EXAMINING ROOM SPACE
Yes
Adequate waiting room space for volume of
people seen
enough seats
comments:
No
Number of exam/treatment rooms
Number of beds
Other
comments:
Adequate number of exam rooms for volume
of patients
at least one exam room per physician
patient’s privacy ensured
confidential areas for discussion
available
comments:
IV. SAFETY/EMERGENCY PREPAREDNESS
A. Safety
Yes
No
Yes
No
Yes
No
Smoke detectors present
Fire extinguishers present
extinguishers checked routinely
Exit signs visible
No-smoking policy
comments:
B. Emergency Preparedness
Emergency equipment
crash cart
emergency kit
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Practitioner Site Review Tool
defibrillator
oxygen
suction
other
Emergency phone numbers posted
Ask three staff members the following question:
If a patient were exhibiting signs of a heart attack: chest pain, shortness of breath, nausea, what
would you do?
comments:
Percentage of staff CPR certified
If a crash cart is present:
Yes
No
written procedure for routinely
checking the cart for pharmaceutical
and sterilized equipment expiration
dates and non-functional equipment
percentage of staff ACLS certified
written procedures for handling cardiac
or respiratory arrest
Staff trained in emergency preparedness
evacuation of facility
written procedures/plan for evacuation
comments:
V. PHARMACEUTICALS/INFECTION CONTROL/EQUIPMENT & TECHNOLOGY
A. Pharmaceuticals
Yes
Stock medications dated
Medication dates monitored
Expired medications discarded
Medications accessible only to appropriate
personnel
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No
Practitioner Site Review Tool
Controlled substances:
clearly identified
secure
written dispensing record
Prescription pads, needles, syringes
inaccessible to patients
comments:
B. Infection Control
Heat
Sterilization/disinfection method:
Chemical
Yes
No
Needles and syringe disposal process
Hazardous waste process
Knowledge on how to report a public health
concern and which diseases/conditions are
reportable by law
comments:
C. Equipment/Technology
please check if applicable:
x-ray
equipment licensed
personnel licensed
badges worn and monitored
Who reads x-rays?
Doppler
EKG
microscope
Incubator
sonography
lab facility
certification/license
equipment calibrated
accredited
hematology
U/A/Chemistry
Yes/Present
date:
how often
by whom
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Practitioner Site Review Tool
other
use outside facility
which facility?
how are results communicated
to patient?
VI. AVAILABILITY OF APPOINTMENTS
Preventative health care
days
days
weeks
weeks
Yes
No
Yes
No
Urgent and emergent care available
same day
seen within two hours
other
who performs triage of these patients
Number of patients scheduled per hour
Average wait time
Method for scheduling extra time for visits, if
necessary
After-hours coverage available
How is this handled? Is written policy available?
VII. PATIENT EDUCATION/RIGHTS
A. Patient Rights
Patients greeted promptly/courteously/friendly
Patients escorted to and from reception area
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Practitioner Site Review Tool
Privacy maintained
policy/procedure regarding
confidentiality
Record available at time of exam
Method for handling complaints and concerns
handled by:
when:
comments:
Policy/procedure forms available
Release of information
Consent for treatment
Refusal of treatment
Treatment of emancipated minor
according to state law
B. Patient Education
Formal programs offered to patients
Informal methods
examples:
VIII. ADEQUACY OF MEDICAL RECORDS KEEPING
Use “Attachment C” Worksheet
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