Earlier this year, the Physician Practice Enhancement Program (PPEP) provided the draft assessment standard for Medical Record for the Dermatologist in a Community-Based Office Setting for external consultation. The program appreciates the time and effort registrants put into their feedback, with a response rate of 42 per cent of practising dermatologists. The program has made several changes to the draft document taking into consideration the extensive feedback received. Feedback received and the changes to the draft assessment standards were reviewed in consultation with the UBC Department of Dermatology and Skin Science.
Specific to dermatology and record keeping, it is recognized that there is a spectrum of dermatologic consultations ranging from focused or regional assessments to comprehensive assessments for complex cases of skin concerns, and the documentation requirements for these may vary significantly.
The program stresses that PPEP assessment standards are not the same as legally enforceable College practice standards. The assessments standards are provided to registrants to ensure that they are aware of the assessment criteria used during a peer practice assessment, and to ensure consistency among peer assessors. The PPEP assessment standard does not replace existing College standards but does reflect them where applicable.
The following changes have been made to the assessment standards:
- Clarification that the PPEP assessment standard is not the same as a College practice standard.
- That the medical record documentation should be sufficient such that another registrant is able to take over care.
- There is recognition that there is a spectrum of dermatologic consultations ranging from focused or regional assessments to comprehensive assessments for complex cases of skin concerns, and the documentation requirements for these may vary significantly. The document explicitly uses the statements “as relevant” or “as indicated” when appropriate to denote that documentation is specific to the problem being assessed.
- This document identifies best practices and expectations, and items noted “M” are mandatory to the extent that it is relevant to the type of consultation being recorded.
The program acknowledges the contributions of dermatologists in the development of this assessment standard: PPEP dermatologist assessors, UBC dermatology partners, and all of the dermatologists who provided their feedback. All PPEP assessment standards undergo review and final approval by the Physician Practice Enhancement Panel, made up of a diverse group of physicians and public members approved by the College Board.