Table 1 Evaluation chart for good clinical practice assessment
Item | Adequate | Inadequate | |
|---|---|---|---|
Medical History | Major information needed to differentiate possible important diagnosis were reported | Insufficient | Important information for clinical decisions was not reported |
Excessive | Useless information collected which could either confuse the patient or the practitioner was reported | ||
Clinical Examination | Appropriate examinations were used in light of the medical history which brings to a reasonable clinical decision were reported | Insufficient | Clinical examination which could have helped for clinical decisions was not reported |
Excessive | An unnecessary clinical exam was reported which could either confuse the patient or the practitioner | ||
Complementary investigations | Investigations were done appropriately in light of the results of medical history and clinical examination and seemed essential for clinical decision. | Insufficient | Results of accessible complementary examination which could have been useful was not reported |
Excessive | Clinically unjustified laboratory tests were done | ||
Referral | Decision to refer or not to refer was taken appropriately | Insufficient | Patient should be referred for additional care but wasn't |
Excessive | Patient was referred without it been necessary | ||
Treatment | Adequate treatment was proposed having taken into consideration the diagnosis and eventual counter-indications. | Insufficient | Appropriate medical treatment not reported |
Excessive | Inappropriate treatment or incompatible treatment with clinical information was reported | ||