Medical Chart Review

Medical Chart Review Barbara Grove, RN National Nurse Consultant John Kulig, MD, MPH Principal Medical Consultant Chart Review • APPROXIMATELY 130 CHARTS ARE REVIEWED BY THE NATIONAL NURSE CONSULTANT YEARLY • APPROXIMATELY 100 CHARTS ARE REVIEWED BY THE PRINCIPAL MEDICAL CONSULTANT YEARLY DURING ROCAs 2 Chart Review – Medical History         3 Illegible Handwriting No Student Identifiers on SF-93 No Report of Medical History (SF-93) Unsigned Report of Medical History (SF-93) Undated Report of Medical History (SF-93) Unreviewed Report of Medical History (SF-93) No Follow-up on Positive Responses Not Completed in the Required Time Frame Chart Reviews – Physical Exams          4 Illegible Handwriting No Student Identifiers on SF-88 No Report of Medical Examination (SF-88) Unsigned Report of Medical Examination (SF-88) Undated Report of Medical Examination (SF-88) No Documentation of Clearance for Sports Participation Cursory Exams Not Completed In 48 Hours Comprehensive Exams Not Completed in 14 Days Pelvic Examinations Omitted Without Documentation of Physician’s Waiver Chart Review- Progress Notes        5 Illegible Handwriting No Student Identifiers on Progress Notes No Entry or Exit Documentation No Pre- or Post-Test HIV Counseling Unsigned Progress Notes Undated and Untimed Progress Notes Clinician’s Title not Included with Signature (MD, NP, PA, RN, LPN, etc.) Chart Review – Immunizations        6 No Prior Immunization Records Required Immunizations Not Given Immunizations Not Current TB Test Not Given TB Test Results Not Recorded Vaccine Information Statements (VIS) Missing Not Using Current VIS Chart Review – TEAP     No TEAP Notes Notes Unsigned Notes Undated Drug Test Reports Not Filed 7 Chart Review - HIV Folders      8 No Case Management No Behavioral Contracts No Documentation of Case Management Team Meetings No Referral Summaries Filed In The Medical Folder No Documentation of Follow-up After Separation Miscellaneous         9 Lab Reports Missing Lab Reports Unsigned Follow-up of Abnormal Lab Values Undocumented Current HIPAA ‘Authorization’ Not Being Used Referrals Not Documented Referral Reports Missing Students Not Referred for Glasses Information That Students Were to Obtain – Missing (Immunizations) Miscellaneous (Cont’d)      10 Complete HIPAA ‘Authorization and Notice’ Forms Not Filed in Folder No Case Management Plans for Students with Chronic Illness or Disability Problem List Missing Medication List Missing Oral Cursory Exam Not Documented Medicaid    Medicaid Is the Payer of Last Resort It Is ILLEGAL for Medicaid to Pay For Basic Health Services as Defined in PRH-6: Exhibit 6-4 Medicaid can be used for specialty referral care, emergency room visits, hospitalizations, surgery, and individual prescription medications 11