Medical Record Standards
- Every page in the medical record contains the patient name or ID number.
- Allergies/No Known Drug Allergies (NKDA) and adverse reactions are prominently displayed in a consistent location.
- All presenting symptom entries are legible, signed and dated, including phone entries. Dictated notes should be initialed to signify review. Signature sheet for initials are noted.
- The important diagnoses are summarized or highlighted.
- A problem list is maintained and updated for significant illnesses and medical conditions.
- A medication list or reasonable substitute is maintained and updated for chronic and ongoing medications.
- History and physical exam documentation identifies appropriate subjective and objective information pertinent to the patient’s presenting symptoms, and treatment plan documentation is consistent with findings.
- Laboratory tests and other studies are ordered, as appropriate, with results noted in the medical record. (The clinical reviewer should see evidence of documentation of appropriate follow-up recommendations and/or non-compliance to care plan).
- Documentation of Advance Directive/Living Will/Power of Attorney discussion (including copies of any executed documents) in a prominent part of the medical record for adult patients is encouraged.
- Documentation of continuity and coordination of care between the PCP, specialty physician (including BH specialty) and/or facilities if there is reference to referral or care provided elsewhere. The clinical review will look for a summary of findings or discharge summary in the medical record. Examples include progress notes/report from consultants, discharge summary following inpatient care or outpatient surgery, physical therapy reports, and home health nursing/ provider reports.
- Age appropriate routine preventive services/risk screening is consistently noted, i.e. childhood immunizations, adult immunizations, mammograms, pap tests, etc., or the refusal by the patient, parent or legal guardian, of such screenings/immunizations in the medical record.
August 2020 Empire Provider News