Evaluation: Well Care

Employee Name*

First Last

Patient Name*

First Last

TRIAGE EVALUATION

Triage*

	YES	NO	N/A
Was the room checked for cleanliness?
Did the medical professional introduce themselves to the patient?
Was the exam room door completely closed?
Did the medical professional start a movie for the patient?
Did the medical professional explain the volume control and movie selection process?
Did the medical professional use hand sanitizer upon entering the room before touching patient and when leaving?
Were the patient’s vitals entered into the EMR using an electronic device while in the exam room?
Were the ASQ question answered in the exam room?
Was the medical history reviewed?
Was the immunization history reviewed?
Was the surgical history reviewed?
Was the medication history reviewed?
Was the social history reviewed?
Was the social history updated to include what grade the child is in school and the starting school year?
Was the medical professional logged into Google email and chat?

Who filled out the ASQ questionnaire?*

If the medical professional, how long did it take her to complete the ASQ questions?*

How long did it take for the medical professional to complete vitals and enter the data into the EMR?*

How long did it take for the medical professional to complete OVERALL triage?*

Vaccine Administration*

	YES	NO	N/A
Were the vaccines to be given verified by another medical assistant?
Was the exam room door completely closed?
Did the nurse use hand sanitizer upon entering the room before touching patient and when leaving?
Were the parents asked if they had any questions prior to administration?
Was an alcohol swab used to clean the skin site prior to injection?
Were the vaccine syringes disposed of in the sharps container in the room?
Were all vaccine supplies (needle caps, bandaid wrappers) thrown away in the trash?
Were the vaccines entered into the EMR accurately?
Was an up to date vaccine record provided to the family prior to discharge?

How long did it take for the medical professional to administer vaccines?*

Comments / Observations / Improvements

Evaluated By*

First Last