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
|
2015
% N/A*
|
2014
% Documented
|
2014
% 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 |
|
Results
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.