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

• 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

• Treatment initiated: Treatment details
• Rationale: Based on guidelines, clinical experience, or evidence?
• Informed consent obtained: Yes / No / Verbal / Written

• 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

• Patient and/or family informed: Clear / Incomplete / Not documented
• Proper clinical records kept: Yes / No / Incomplete
• Relevant notes:
  1. Comments on clarity, chronology, and clinician’s signature

• Level of clinical diligence observed:
  1. [ ] Excellent
  2. [ ] Adequate
  3. [ ] Deficient
  4. [ ] Negligent
• Justification: Brief evaluator's comment

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