PEA - CPE Adult-CPE I Adult Instructions

CPE I Adult Instructions

Pdf Summary

The Clinical Practice Evaluation (CPE) I for Medical Record Review targets adult patient populations in preventive medicine, assessing the documentation processes for 10 randomly selected patient medical records. This evaluation is divided into several key parts: <br /><br /><strong>Part A</strong> involves recording identifying information: the review date, a patient-specific identifier, the latest visit date, patient gender, and age.<br /><br /><strong>Part B</strong> reviews risk factors for various health conditions. Records are checked for documentation on risk factors, with responses categorized as Yes, No, or N/A based on whether the assessment is appropriate for the patient’s age or gender.<br /><br /><strong>Part C</strong> assesses documentation for diagnoses of listed health conditions using the labels Yes (presence of diagnosis), No (absence of diagnosis), or Unsure (unclear documentation). Any diagnosed conditions not listed should be noted under "Other."<br /><br /><strong>Part D</strong> focuses on objective findings and includes the documentation of physical measurements such as weight, height, BMI, blood pressure, and latest lipid profile readings.<br /><br /><strong>Part E</strong> examines screening records for recommended health conditions as per the United States Preventive Services Task Force (USPSTF) guidelines. It labels records as Yes, No, Unsure, or N/A, and notes the specific screening tests used if applicable.<br /><br /><strong>Part F</strong> evaluates documented patient counseling and chemoprevention interventions based on current USPSTF and CDC guidelines. The form also checks for conditions that limit the patient’s ability to perform daily activities (ADLs), categorized similarly – Yes, No, or Unsure.<br /><br />After completing reviews for ten patient charts using the provided forms, all documentation must be retained and submitted to the American College of Preventive Medicine. This process ensures comprehensive and accurate patient care documentation, integral for quality improvement initiatives. Completion of both CPE I (adult/pediatric) and CPE II, a Clinical Systems Review, is required to fulfill the Diplomate Practice Assessment Plan (DPAP).

Keywords

Clinical Practice Evaluation

Medical Record Review

preventive medicine

adult patient

documentation processes

risk factors

diagnoses

objective findings

screening records

patient counseling