Page 438 - eBook Version 8 Book 1 of 2 JUL 2022

Visit Type: Research
Principal Investigator
Title of Study/IRB#
Location of Visit
State any education provided
Visit Note Worksheet
Chief Complaint (Research Participant):
Address inclusion / exclusion criteria
Adverse events and concomitant medications were reviewed
Assessments and procedures performed at this visit per protocol:
Vital Signs, Height, Weight, etc. (in Visit Note or in EPIC)
Medication administered (if indicated)
Labs obtained by___ (if applicable)
Physical exam performed by (MD name) if applicable
Subject returned investigational product?
Study questionnaires administered prior to study procedures (if indicated)
Patient tolerated procedures and assessments (well, with difficulty, etc)
Patient, Parents, Mother, Father verbalized understanding of education provided at this visit.
Next visit is scheduled for: Month/Year
Documentation of ALL study related procedures and medications
Documentation of patient's response to all study procedures and medications
Education is provided in primary language (documentation of interpreter used) if not English
Documentation that patient education was provided related to the study
Documentation that patient was informed of study follow up plan
Documentation that parent's verbalized understanding of information
Standard/ Policy/ Gudance
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Joint Commission
Location
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
EPIC: progress note or scanned doc.
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Present in Chart (Circle ONLY one)
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Notes
Auditor Initials________________________________
MR#_________________________________
Date____________________________
FOR AUDIT PURPOSES ONLY