Assessment Report
July 1, 2009- June 30, 2010
Program Assessed: Student Health Services
Assessment Coordinator: Leatha Ross, MS, FNP-BC
Year 2009 to 2010 - one year cycle
1. ASSESSMENT MEASURES EMPLOYED

Surveys
Patient satisfaction surveys and chart audits are performed yearly. During the winter
quarter an online survey was conducted. The survey was made available to all
registered students.
Chart Audit
 A yearly chart audit is performed on providers.
 Charts are pulled randomly by the Office Personnel for each provider for
review. The classifications include: Acute, episode care and well,
preventative care.
 SOAP notes are reviewed for completeness. Areas assessed are
documentation of height/weight, vital signs, laboratory results if ordered, the
medication flow sheet for accuracy and completeness,
counseling/preventative teaching and documentation of follow-up.
 This is a peer-review process. Each provider is given another provider’s
charts. The reviewer has specific criteria to review. A check mark is placed
indicating whether or not it is complete.
 Completed QA is given to the director for analysis. Deficiencies are noted
and discussed with the provider. Results are used in yearly performance
reviews.
Annual Statistics



The number and type of visits are recorded daily.
RN’s keep track of each visit on a clipboard. A record is made of who saw the
student, what type of visit, whether lab tests were sent, injections given,
treatments given, and/or the relative complication of the visit.
Results are compiled by the RNs, reviewed and compared monthly by the
director, and shared with staff at staff meetings.
1
2. ASSESSMENT FINDINGS
Objectives
1. The number of patient visits will increase by 200 visits from the previous the
year as calculated from annual statistics.
2. Students who receive health care at student health will report 100%
satisfaction
3. The providers will achieve 100% completeness from yearly chart audits.
Complete and accurate medical information is necessary for providing safe
health care.
Outcomes
Annual Statistics

The number of provider visits was down by 109 - (4017 in 2009; 3908 in
2010). The number of total visits was up by 68 visits from the previous fiscal
year (7953 in 2009; 8021 in 2010). The decrease in provider visits may be due
to staff illness in the clinic. We do staggered lunch hours so that we can
accommodate students over lunch hours. However, during the months of staff
illness the clinic was closed over lunch. More students may be aware of our
location which is emphasized during orientation. The increase in visits may be
a reflection of these changes as well as advertising through the website
Random Walk-out Surveys


Patient satisfaction surveys and chart audits are performed yearly. The data
collected in 2010 represent responses to an online survey. Two hundred
(200) students started the survey and 165 (82.5%) completed the entire
survey. Approximately 90% of those who completed the survey were
satisfied with the wait time before being seen by a provider, the care
received and interaction with office and clinical staff. An area of concern
noted by the students is the openness of our waiting room. Ninety percent
believe their visits are handled in a confidential manner. However, some
60% were concerned about the waiting room.
Chart Audits
Random chart audits included 12 charts. All charts reviewed had 98% completion.
Two percent of the charts reviewed had omitted a statement of follow-up or
disposition.
3. PROGRAM IMPROVEMENTS
Confidentiality
Confidentiality continues as an area of concern even in our new space. Periodic staff and
receptionist meetings are held to discuss problems that develop. We continue to identify
2
ways to ensure confidentiality and provide better service to our students. A sign-in sheet
was developed that requires the student to indicate their name, UID number, and to check
which service they seek. This prevents the need for the student to discuss their health
sensitive information while others are seated in the lobby.
Standards
SHS has adopted the AAAHC standards that are applicable to our setting as
recommended by the internal auditors.
Electronic Medical Record
In June 2010 Student Health Services implemented electronic medical record. The system
is provided through a vendor, Point N Click. Electronic medical record has improved
efficiency, timeliness of providing care to our students, quick access to reports and
student records. The system assures accurate and readable information. All health
sensitive information incorporated in the electronic medical record is maintained on a
secured server which is maintained at Wright State’s computing center.
4. ASSESSMENT PLAN COMPLIANCE
A simple redesign of the front desk area would enhance the protection of private medical
conversations. We have met with engineering to look at plans and determine if a simple
redesign is possible. This is still in progress.
In an effort to consider budget constraints, a sign-in sheet has been instituted that allows
the student to check reason for visit, name, and UID number. This process continues to
decrease the need to discuss medical problems while in the waiting area, which will
further enhance and maintain confidentiality. We will continue with this plan.
5. NEW ASSESSMENT DEVELOPMENTS
Ideas, suggestions, medical updates are constantly being discussed and applied, if
determined to be beneficial.
On-line satisfaction student health survey
In the future Open Communicator, a web-based portal that allows students to access a
satisfaction survey, will be utilized. Students will be able to complete surveys in real-time
and a randomized fashion. Data will be readily available for analysis.
On-line Medical History Form
A key feature of this system provides the student access to a medical history form.
Requiring completion of the document and storage on a secure server will meet
university policy for residential and international students. The process should increase
compliance.
3
Business Continuity Program
Student Health has worked with Risk Management to develop a plan for continued
provision of health services to our students in the event of a major disruption in services.
Currently we are in Phase 2 of the development process.
4