PPR-NL Facility and Process Questionnaire - Family Medicine

Step 1 of 7 - Patient Appointments

Section 1: Patient Appointments

What process, if any, is used to keep a record of the patient visits made to your practice each day (e.g., paper day log, EMR)?.(Required)

How would a patient of your practice typically arrange to see you for a new health problem?(Required)

How long would a patient in your practice usually wait for a non-urgent appointment?(Required)

What, if any, process is in place to triage appointment requests by acuity?(Required)

Does your practice provide after-hours care (that is, outside weekday daytime hours) for your patients?(Required)

Yes

N/A

Section 2: Access

Briefly describe the procedures, if any, used to ensure the follow-up for your patients after a referral or consultation, hospital admission or out-patient investigation?(Required)

Does your office have the capacity to accommodate patients with urgent health complaints (that is, same or next day)?(Required)

Yes

N/A

If, YES, describe below(Required)

How many chairs/spaces are available to patients in your waiting area?(Required)

How many examination rooms are typically available for your use?(Required)

Do any barriers exist to accessing your office by patients with disabilities?(Required)

Yes

N/A

If, YES, describe below(Required)

Are your office washrooms accessible to patients?(Required)

Yes

N/A

Are your office washrooms accessible to patients with disabilities?(Required)

Yes

N/A

Do you have any concerns regarding facility access not addressed above?(Required)

Yes

N/A

If, YES, describe below(Required)

How do you typically ensure care for your patients when you are absent from the office for extended periods (that is, a week or more)?(Required)

Section 3: Confidentiality

How do you ensure the privacy and confidentiality of your patients during examinations and consultations?(Required)

What safeguards are present in your office to prevent unauthorized viewing of patient records?(Required)

Section 4: Record-Keeping

What medical record system is used in your primary practice location (paper, EMR or combination)?(Required)

Does each individual patient have his or her own chart?(Required)

Yes

N/A

If, NO, describe below(Required)

Briefly describe the process for the receipt, review and filing of external consultations, discharge summaries and investigations reports.(Required)

What procedure, if any, is used to ensure that patients receive screening measures (e.g., PAP smears, colonoscopy, etc.) at appropriate intervals?(Required)

What procedure, if any, is used to ensure the regular monitoring of patients with chronic conditions (e.g., HgbA1C, eye checks for patients with diabetes)?(Required)

Section 5: Equipment

Indicate which of the following equipment is present in your office:

An examination table in each examination room.(Required)

Yes

N/A

Ophthalmoscope(Required)

Yes

N/A

Hand washing sink in each examination room.(Required)

Yes

N/A

Reflex Hammer(Required)

Yes

N/A

Hand cleansing station(s) in waiting and patient care areas.(Required)

Yes

N/A

Measuring Tape(Required)

Yes

N/A

Stethoscope(Required)

Yes

N/A

Scale(Required)

Yes

N/A

Sphygmomanometer(Required)

Yes

N/A

Thermometer(Required)

Yes

N/A

Otoscope and clean tips(Required)

Yes

N/A

Vaginal Specula(Required)

Yes

N/A

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Indicate which of the following equipment is present in your office:(Required)

	Yes	No	N/A
An examination table in each examination room.
Hand washing sink in each examination room.
Hand cleansing stations in waiting and patient care areas.
Stethoscope
Sphygmomanometer
Otoscope and clean tips
Ophthalmoscope
Reflex hammer
Measuring tape
Scale
Thermometer
Vaginal Specula

Section 6: Safety and Infection Control

What measures are taken to prevent unauthorized access or theft or prescription pads?(Required)

How are drug samples stored or secured within your office?(Required)

How are expiry dates and lot numbers tracked for vaccines?(Required)

Does the refrigerator used for vaccine storage have an alarm?(Required)

Yes

N/A

Does the refrigerator used for vaccine storage have a temperature monitor/recorder?(Required)

Yes

N/A

Briefly describe your process for disposing of sharps and biomedical waste.(Required)

Briefly describe your process for the cleaning and sterilization of any reusable medical instruments.(Required)

Section 7: Emergency Preparedness

What is the approximate response time to your practice for an Emergency Medical Services 911 call?(Required)

Indicate which of the following emergency equipment is present in your office:

An assist device or mask or artifical respiration(Required)

Yes

N/A

An automated external defibrillator(Required)

Yes

N/A

Epinephrine for SC or IM injection(Required)

Yes

N/A

This field is hidden when viewing the form

Indicate which of the following emergency equipment is present in your office:(Required)

	Yes	No	N/A
An assist device or mask for artificial respiration
an automated external defibrillator
Ephinephrine for SC or IM injection

I attest that the above is an accurate reflection of my main office practice(Required)

I acknowledge that I have read and understand the above statement.

Full Name(Required)

First

Date(Required)

MM slash DD slash YYYY

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