2015 MediSource Medical Record Review Results

The Clinical Quality Department performed a mandatory medical record review in the third quarter (Q3) of 2015 to ensure that practitioners are documenting in accordance with Independent Health's medical record criteria and the NYS Department of Health requirements.

A sample of 165 random MediSource office records from various providers in the community were reviewed for all required medical record documentation criteria with a focus on preventive services, prevention and treatment of sexually transmitted diseases (STDs), tuberculosis screening, diagnosis and treatment, the offering of HIV testing, and provision of Mental Health and Chemical Dependency Services. The records were grouped into the following three age categories:

  • Ages 2-11 - Fifty Two (52) records
  • Ages 12-29 - Thirty one (31) records
  • Ages 30+ - Eighty two (82) records

The overall results are presented in the table below, along with the 2014 results to be used as a comparison.

*Not applicable due to eligibility requirements or patient refusal.
Medical Record Review Component 2015
% Documented
% N/A*
% Documented
% N/A*
History 99 100
Physical 99   99  
Allergies 94
96 75
If allergies, reaction documented 18 62 11 5
Problem list 96 2 94 16
Medications 92 7 84  
Documentation of clinical findings 100 100
Plan of care 100 100
Age appropriate preventive services/screening 86 77
Advanced directives or discussion 10 49 4 62
TB assessment 5   22  
TB testing 4 1 9 10
STDs assessment 16 32 36 39
STDs testing 2 46 10 51
Behavioral Health Assessment 86   55 26
Substance Use Assessment (12 & older) 52 31 50 34
Tobacco Use Assessment (12 & older) 61 31 81 16
HIV testing offered (13-64) 8 35

The above results indicate there are many areas where documentation is excellent; however; there is opportunity for improvement in documentation for TB assessment and testing, sexually transmitted disease assessment and testing, offering HIV testing, and mental health and chemical dependency.

Ninety-five percent of records reviewed were electronic medical records (EMR). This type of record enables practitioners to obtain a more comprehensive health assessment of the patient by utilizing prompts that incorporate clinical practice guidelines for disease management and preventive screenings, clinical health alerts and reminders. Many EMRs already have the necessary prompts to meet the required documentation as indicated above but are not being completed. Those that do not have the necessary prompts for the required documentation can have them updated and incorporated into the EMR by working with their respective IT departments or EMR vendors. Those that still have paper records are severely limited in incorporating the required documentation due to not having a structured format that can be consistently followed for a comprehensive health assessment. The 5 percent of handwritten records that were reviewed failed to assess for TB, STDs, HIV or behavioral health and chemical dependency. The handwritten records were difficult to read and lacked detailed assessment and recommendations for preventive services.

The following information is meant to make you aware of the importance of assessing and documenting TB, STDs, HIV testing, and behavioral health and chemical dependency in your patient's medical record:

  • Tuberculosis - All patients should be assessed and then tested for TB when indicated. If a patient is found to have a positive response to a PPD, in the appropriate clinical circumstances, prompt action should be taken to report to the local health department followed by a submission of the confidential case report form, which can be found at www.health.ny.gov/forms/instructions/doh-389_instructions.pdf or call (518) 473-4439. Reporting of suspected or confirmed communicable disease is mandated under the New York State Sanitary Code. The primary responsibility for reporting rests with the physician.
  • Sexually Transmitted Diseases - Practitioners should be providing adolescents and young adults with routine counseling and education associated with sexual activity, including assessment and testing for STDs. This assessment and testing should be reflected in the member's record. Reporting of a suspected or confirmed STD to the local health department is mandated.
  • HIV - Practitioners are required to offer HIV testing as part of routine care for all persons ages 13 - 64. The New York Public Health Law allows for oral patient consent to an HIV test. Reporting of positive findings to the NYS Department of Health or the local health department is mandated.
  • Behavioral Health and Chemical Dependency - Documentation in a member's record should include an assessment/screening for behavioral health issues, including depression and chemical dependency. Mental health services should be provided when indicated. Members may also be referred to Independent Health's Case Management program.