Clinical Diligence Evaluation [Neurosurgery Wiki]

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====== Clinical Diligence Evaluation ======

**Patient:** %%Patient's name%%  
**ID:** %%Patient ID or record number%%  
**Age:** %%Age%%  
**Case date:** %%DD/MM/YYYY%%  
**Responsible clinician:** %%Physician's name%%

===== 1. Initial Assessment =====
  * **[[Chief complaint]]:** %%Brief description of the reason for consultation%%
  * **Complete history taken:** %%Yes / No / Partial (specify)%%
  * **[[Physical examination]] performed:** %%Yes / No / Incomplete%%
  * **Complementary tests requested:** %%List of tests%%
  * **Initial diagnosis:** %%Working or confirmed diagnosis%%

===== 2. Clinical Decision-Making =====
  * **Treatment initiated:** %%Treatment details%%
  * **Rationale:** %%Based on guidelines, clinical experience, or evidence?%%
  * **[[Informed consent]] obtained:** %%Yes / No / Verbal / Written%%

===== 3. Follow-up and Reevaluation =====
  * **Subsequent check-ups done:** %%Yes / No / Not applicable%%
  * **[[Review]] of results:** %%Accurate interpretation of tests and clinical evolution%%
  * **Treatment adjusted if needed:** %%Yes / No / Not applicable%%

===== 4. Communication and Documentation =====
  * **Patient and/or family informed:** %%Clear / Incomplete / Not documented%%
  * **Proper clinical records kept:** %%Yes / No / Incomplete%%
  * **Relevant notes:**  
    - %%Comments on clarity, chronology, and clinician’s signature%%

===== 5. Overall Assessment =====
  * **Level of clinical diligence observed:**  
    - [ ] Excellent  
    - [ ] Adequate  
    - [ ] Deficient  
    - [ ] Negligent  
  * **Justification:** %%Brief evaluator's comment%%

----

**Evaluator:** %%Evaluator's name%%  
**Date of evaluation:** %%DD/MM/YYYY%%