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1
2
3
4American
Improvement in Medical Practice (PIP) Audit
Board of
Psychiatry and
Neurology, Inc.
A Member Board of the American Board of Medical Specialties (ABMS)
Name:
ABPN ID #:
Clinical Module
I.
If you completed an ABPN-Approved Product for the Clinical Module please provide the following:
Sponsor/Organization _____________________________________________________
Title of Activity _________________________________________________________
Date Completed: _________________________________________________________
*Please also include a copy of your Certificate of Completion. You do not need to fill out the
reminder of Component 1: Clinical Chart Review Module information if you did an ABPN-Approved
Product. If the product only featured the Clinical Module, you will need to fill out the Feedback
Module.
Step A- Measurement
Fill out the following Clinical Module information if you did an Individual Pre-Approved PIP unit, or
completed a PIP prior to 2014.
1. List date(s) of initial review of 5 patient charts: ___________________________________
2. Check and describe the specific category (choose one) of focused improvement for the chart
reviews:
☐ Diagnosis
☐ Type of treatment
☐ Treatment setting
☐ Other
3. List the published practice guidelines referenced (i.e. APA, AAN guidelines, etc.):
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