CONTINUOUS QUALITY IMPROVEMENT

CPG MONITORING

UNIT: __________________________ DATE: _______________________ TIME: _______________

PATIENT: _____________________________ ATTENDING PHYSICIAN: ________________________
DIAGNOSIS: _______________________

DIRECTION: CHECK APPROPRIATE COLUMN

CRITERIA YES NO REMARKS
1. Patient Presenting Signs & Symptoms
1.1 Correct assessment of patients signs & symptoms
1.2 Laboratory tests are done for confirmation of signs and
symptoms
1.3 Initial diagnosis identified based on patients’ signs and
symptoms and result of laboratory and diagnostic test based on
CPG of disease
2. Doctor’s Order
2.1 STAT medications are ordered and carried out
2.2 Doctor’s order in generic name
2.3 Treatment regimen for disease condition is followed
2.4 Special procedures/referrals are carried out as started in
the CPG of disease.
3. Doctor’s Progress Notes
3.1 Medication are explained to the patient
3.2 Procedures to be done are explained.
3.3 Referrals to higher facility done when needed.
3.4 Allergies to medications and food are noted.
3.5 Unusual observations are properly observed/noted and
referred.
3.6 Review of medications from IV to PO for patients who are
clinically stable and able to tolerate orally
3.7 Timing, regimen dose, route of administration and duration
of antimicrobial therapy are regularly reviewed and
optimized.
TOTAL: 15 GRAND TOTAL:

SCORING: YES

TOTAL: 15 -13 - OUTSTANDING

12 -10 - VERY SATISFACTORY
9–7 - SATISFACTORY
6–4 - GOOD
3–1 - NEEDS IMPROVEMENT

NOTE: For questionnaire with NO answers, will be discussed and solutions will be recommended and
implemented for improvement

Findings/Remarks:______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Recommendation/For
Improvement:_________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Noted By: ________________________________________ Date: ____________________

Quality Assurance Program, Committee Member