Patient Medical Record Forms

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					                        GUIDELINES
           CONRADPQI MEDICAL RECORD REVIEW TOOL

RECORDS REVIEW:

   1. Medical Records are kept secure and confidential.
      Guidelines:
      • Confidentiality of physical exams, physician consults, test scheduling, and waiting
         for care.
      • There is a systematic method for maintaining, transporting, and storing medical
         records that protects the safety of the record and the confidentiality of patient
         information.
      • Office personnel are knowledgeable of the office's system for medical record
         keeping.
      • Medical Record storage inaccessible to patients
      • Record is clearly organized and does not contain information from other patients.
      • Patient record is available at time of examination.

   2. Each page in the record contains the patient's name or identification number.
      Guidelines:
      • Patient identification is documented on both sides of each page in the medical
         record (if both sides are used).
      • Patients may be identified either by name or unique identification number.
      • For re-review and re-credentialing audits, documentation should only be considered
         with dates of service after the last review.

   3. Each record contains appropriate biographical/personal data.
      Guidelines:
      • Biographic/personal data is present on the medical record. This should include
         address, employer, home and work telephone numbers, person to notify in case of
         emergency, date of birth, gender and marital status.

   4. Each author is identified on each entry.
      Guidelines:
      • Either the initials or the name of the examining physician is noted on each patient
         encounter. (When initials are used, there is a designation of signature and status
          maintained in the office)
      •   Physician Assistants' notes are co-signed by physician.
      •   Transcribed notes are initialed by author.
      •   Identification may be handwritten, initials-stamped signature, or electronic.

   5. All entries are dated.
      Guideline:
      • Self-explanatory
Standard Record Review Guidelines
Page 2

     6. The record is legible to someone other than the writer.
        Guidelines:
        • The medical record is legible to the reviewer.
        • If not, the reviewer should request a member of the office staff to read the illegible
           portion of the record. The results should be noted in the comments section.
        • If illegible to both the reviewer and office staff, copies of representative samples
           may be made and reviewed by the medical director or designee, who may overrule
           the reviewer.

     7A. There is a completed problem list.
         Guidelines:
         • A completed, current list of problems including significant illness and medical
            conditions is documented in the medical record.
         • This can be in the form of an actual Problem List or a notation in the progress notes
            for each encounter of chronic, ongoing problems.
         • Examples include, but are not limited to:
              Diabetes
              Hypertension
              Asthma
              CAD
         • For Specialty Care Providers, the problem list should contain information pertaining
            to the care being provided. Remaining information may be documented in the
            medical history.

     7B. A listing of medications should be easily found within the chart and should
         contain all known medications currently being used by the patient.
        Guidelines:
        • Drug name, dosage, frequency and duration are noted when prescribed.
        • Injections are charted to include drug name, dosage, route and site.
        • Notation is made when sample drugs are provided.
        • Refills are noted.
        • Documentation may be in progress notes or medication flow sheet.
        • This list should be updated each visit.

     8. Allergies and adverse reactions to medications are prominently noted in the
        record.
        Guidelines:
        • Allergies and adverse reactions are documented in the same location of all medical
           records reviewed.
        • Location is consistent throughout the practice.
        • Medical records of patients with no known allergies or adverse reactions must be
           documented as such, e.g., NKA, NKDA.
Standard Record Review Guidelines
Page 3

     9. There is an appropriate past medical history in the record.
        Guidelines:
        • A past medical history is present on the medical record that identifies serious
           accidents, operations, and/or illnesses for patients who have been seen at least three
           or more times.
        • For children and adolescents (18 years and younger), past medical history relates to
           prenatal care, birth, operations, and childhood illnesses.

     10A. There is documentation of tobacco habits for members 11 years and over, and
        seen 3 or more times.
        Guidelines:
        • Documentation of tobacco history/habits is present on medical records of patients
           11 years of age or older who have been seen by the practice at least three or more
           times.
        • Documentation of tobacco history/habits of patients younger than 11 years of age,
           if appropriate, is present.
     10B. There is documentation of a history of alcohol use for members 11 years and
        over, and seen 3 or more times.
        Guidelines:
        • Documentation of alcohol history/habits is present on medical records of patients 11
           years of age or older who have been seen by the practice at least three or more
           times.
        • Documentation of alcohol history/habits of patients younger than 11 years of age, if
           appropriate, is present.

     10C. There is documentation of a history of substance abuse for members 11 years
        and over, and seen 3 or more times.
        Guidelines:
        • Documentation of substance abuse history/habits is present on medical records of
           patients 11 years of age or older who have been seen by the practice at least three or
           more times.
        • Documentation of substance abuse history/habits of patients younger than 11 years
           of age, if appropriate, is present.

     11. The history and physical exam identifies appropriate subjective and objective
         information pertinent to the patient's presenting complaints.
         Guidelines:
         • Documentation of only "Exam normal" or "Exam WNL" (or other similar
             notations) that do not describe the objective and subjective findings is NOT
             acceptable.

     12. Lab and other studies are ordered as appropriate.
         Guidelines:
         • Diagnosis indicates the need for labs or other studies.
         • Documentation verifies that the same were ordered.
Standard Record Review Guidelines
Page 4

         •   If the studies are ordered appropriately, the physician will not be faulted for non-
             compliance by the patient.
         •   If the reviewer believes that either appropriate studies/labs were not ordered or
             inappropriate studies were ordered, a copy of the record, with patient identification
             removed, will be forwarded to the medical director or designee for review.

     13. Working diagnoses are consistent with findings.
         Guidelines:
         • The diagnosis noted on the medical record is consistent with the symptoms and
            physical exam or other diagnostic findings.
         • If the reviewer believes the diagnosis listed is not supported by symptoms and/or
            physical exam or other diagnostic findings, a copy of the record, with patient
            identification removed, will be forwarded to the medical director or designee for
            review.
         • This does not include listed diagnoses that have been previously ruled out.

     14A. Plans of action/treatment are consistent with diagnosis(es).
        Guidelines:
        • If the reviewer believes the treatment plan/actions are not consistent with the
           diagnosis, a copy of the record, with patient identification removed, will be
           forwarded to the medical director or designee for review.

     14B. There is evidence of patient/'significant-other' teaching.
         Guidelines:
        • Documentation must be present which reflects that patient/responsible party teaching
        has occurred in situations where teaching is needed. (Examples: new medications, new
        procedures, new testing, etc.)

     15A. For each encounter there is a date for return visit or other follow-up plan.
        Guideline:
        • Most entries in the record indicate a follow-up visit.
        • Acceptable documentation includes:
             "Call if no better."
             Return to Office (RTO) ____days/weeks/months."
             "RTO PRN."
        • If the patient is referred for testing, there should be documentation that indicates
           follow-up after review of the test results.
        • If the patient is referred to a specialist, there should be documentation such as "
           return PRN."

     15B. There is documentation of "No-Shows" and follow-up of "No Shows".
        Guidelines:
       • There is documentation of failure of patient to keep appointment.
       • Documentation includes three follow-up(s) when patient fails to keep appointment.
       • One follow-up may be via telephone and two must be written.
Standard Record Review Guidelines
Page 5

     16. Problems from previous visits are addressed.
         Guideline:
         • The medical record reflects continuity of care and appropriate follow-up from
         previous visits,
            including unresolved problems.

     17. There is evidence of appropriate use of consultants.
        Guidelines:
        • There is review for under utilization/over utilization of consultants.
        • Documentation supports appropriate and timely use of consultants, i.e., there is a
           need for a referral and the referral is ordered in a timely manner.
        • If the reviewer believes consultants were used when not indicated or not used when
           indicated, a copy of the record, with patient identification removed, will be
           forwarded to the medical director or designee for review.


     18. There is evidence of continuity and coordination of care between primary and
         specialty care providers.
         Guideline:
         • If a consultation is requested, there is a note from the consultant in the record.
         • Documentation of telephone calls.
         • Results of consultations are documented.
         • When a patient receives services at or through another provider, such as a hospital,
            emergency care, home care agency, skilled nursing facility or behavioral health
            specialist, there is evidence of coordination of care through consultation reports,
            discharge summaries, status reports or home health reports. (Discharge summary
            includes the reason for admission, the treatment provided and the instructions given
            to the patient in discharge)

     19. Consultant summaries, lab, and imaging study results reflect primary care
         physician review.
         Guidelines:
         • Consultation, lab, and imaging reports filed in the chart are initialed by the primary
            care physician to signify review.
         • Review and signature by professionals other than PCPs, such as nurse practitioners
            and physician assistants, do not meet this requirement.
         • If the reports are presented electronically, or by some other method, there is also
            representation of physician review.
         • Consultation, abnormal lab, and imaging study results have an explicit notation in
            the record of follow-up plans.

     20. Care provided appears to be medically appropriate for the diagnosis/conditions.
         Guideline:
         • There is no evidence that the patient is placed at inappropriate risk by a diagnostic
            or therapeutic procedure.
Standard Record Review Guidelines
Page 6

         •   If the reviewer believes the care may be questionable, a copy of the record, with
             patient identification removed, will be forwarded to the medical director or
             designee for review.

     21. There is a completed immunization record in accordance with the organization's
         practice guidelines.
         Guideline:
         • An immunization record for children is up-to-date.
         • An appropriate history has been made in the medical record for adults.

     22. Preventive services are appropriately used.
         Guidelines:
         • There is evidence that preventive screening and services are offered in accordance
       with the organization's practice guidelines.
       • Adults and adolescents should be assessed for high-risk behaviors and safety issues.
       • Pediatric patients should be assessed for safety issues and development milestones.
       • Counseling, as appropriate to high-risk behavior and safety issues, should be
   documented.

    23. There is documentation of discussions of a living will or advance directives for
   patients 65 years of age or older, or for patients with a life-threatening condition(s).
        Guidelines:
        • A note regarding discussing of living will/advance directives should be present in the
      medical record.
        • If a living will or list of advance directives exists, a copy should be present in
      medical record.

    24. Phone calls to and from the patient are documented.
        Guidelines:
        • Pertinent phone calls to and from the patient, including phone calls notifying the
   patient of diagnostic testing results or requesting prescription refills, should be recorded on
   the medical record or an alternative documentation system that is retained by the practice.
        • Any return-call forms, (i.e: stick-ons used when a provider is on call) are acceptable
   and should be affixed permanently in the patient medical record.
        • Requests for prescription refills should be documented to include the name of the
   pharmacy where the prescription was called, the medication(s), dosage, administration
   directions, and refills.

Revised: June 10, 2005 - cc

				
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Description: Patient Medical Record Forms document sample