Medicare 2015 Medical Record Review Results

The Clinical Quality Department recently performed medical record reviews to ensure practitioners are documenting in accordance with Independent Health medical record criteria and Centers for Medicare and Medicaid Services (CMS) Guidelines.

A random sample of 203 Medicare office medical records was reviewed for history, physical exam, allergies and reactions; problem list; medications; documentation of clinical findings plan of care; age appropriate preventive services and advance directives.

The overall results are presented in the table below, along with the 2014 results, which serve as the baseline for comparison in annual reporting.

*Not applicable due to eligibility requirements or patient refusal.
Medical Record Review Component 2015
% Documented
% N/A*
% Documented
% N/A*
History 99.5 99.5
Physical 99.5 99.5
Allergies 97
78 14
If allergies, reaction documented 23 45 27 33
Problem list 98.5 95
Medications 100 78 99 .5
Documentation of clinical findings 100 100
Plan of care 100 100
Age appropriate preventive services/screening 67 59
Advanced directives or discussion 40 53


Overall documentation was very good; however, opportunities for improvement include addressing advance directives, documenting reactions to allergies, and preventive services.

  • Advance Directives
    Advance directives should be addressed for all patients over 18 years of age. A patient's record should include a copy of the advance directive, if the member has one, along with documentation that a discussion regarding advance directives took place or that the member declines to have a Health Care Proxy (as verification of the discussion).
  • Allergy
    When a patient has a documented allergy, the adverse reaction should also be identified and included in the record.
  • Preventive Screening
    Age-appropriate immunizations and other preventive screenings or tests according to Independent Health's clinical guidelines should be reviewed at each annual visit.