Contact Us
Plans and Services Health and Wellness About Wellmark Member Employer Broker Provider
Medical Record Indicators and Measures

Wellmark, Inc. believes that the medical record is the single key source of information pertaining to a patient's health status and needs. Therefore, it is important that the medical record be maintained in a manner that allows for consistent, thorough documentation, accessibility, and confidentiality of patient information.

 

In support of this belief, Wellmark, Inc. has adopted a uniform set of medical record standards for use by all participating network providers.

 

The medical record keeping system must include:

  • A systematic method for medical record keeping, which could include alphabetical order, color coding, numerical order, or computerized record keeping.
  • A backup system for obtaining medical records during down time for records, which are computer stored.
  • A written policy/procedure addressing confidentiality of medical record information that includes a signed statement by staff acknowledging the policy/procedure.

The medical record itself should contain the information as outlined below and on the subsequent pages.

Indicator Met Not Met
1. Each page of the medical record contains patient name or ID number. Patient name or ID number is on each piece of paper in the medical record. An exception to this would be a document such as a consultation report, a letter or hospital discharge summary that contains two or more pieces of paper. In cases such as this, patient name or ID number on the first page is acceptable. Patient name or ID number is not documented on each piece of paper in the medical record. (See exceptions under "Met.")
2. Biographical/ personal data are available.1 Patient name or patient identifier, address, employer, home and work telephone numbers, and marital status are documented. Biographical/Personal data written on the folder of a medical record are acceptable. Biographical/personal data are not documented in the record or on the folder as stated in the "Met" column. If there are spaces for biographical/personal data as stated in the "Met" column that are not filled in, this indicator will be considered "Not Met."
3. There is a completed problem list. For adults, a problem list is present and includes chronic conditions and/or treatment for the same acute illness resulting in 3 or more visits within 24 months.

 

For children or adolescents (18 years and younger), a problem list is present and includes chronic conditions and/or treatment for the same acute illness resulting in more than 4 visits within 6 months or more than 6 visits within 12 months.

For adults, a problem list is not present or is present, but does not include chronic conditions and/or treatment for the same acute illness resulting in 3 or more visits within 24 months.

 

For children or adolescents (18 years and younger), a problem list is not present or is present, but does not include chronic conditions and/or treatment for the same acute illness resulting in more than 4 visits within 6 months, or more than 6 visits within 12 months.

 

Not applicable if there is no indication of chronic conditions and no acute illnesses meeting the visit thresholds indicated under the "Met" column.

4. All entries are dated.1 The month, day, and year are documented for each entry in the medical record. In cases where a prenatal flow sheet is used, one would expect to see the month, day and year documented for the initial visit, the month and day for subsequent visits, and the month, day and year in cases where a new year occurred during the pregnancy. (Loose papers and telephone slips are not considered an entry.) The month, day, and year are not documented for each entry, with the exception described in the "Met" column.
5. All entries are legible. The reviewer is able to read sufficient words in each entry in the progress note to understand the content. To facilitate comprehension, the reviewer may request a list of abbreviations and their meanings. If the reviewer has difficulty reading the documentation, the reviewer may ask the office staff to read one or two entries. The reviewer is not able to read sufficient words in order to understand the content.
6. Presence or absence of medication allergies and/or adverse reactions is prominently noted in the record. Allergy status and/or adverse reaction status is prominently noted in the record. Examples of "prominently noted" would include placement of the status in or on the front of the folder or consistent placement in each record. Prominent documentation of allergy status and/or adverse reaction status is not present. Notation of allergy status and/or adverse reaction status on ancillary documents or in the narrative of the progress note is not adequate.
7. Pediatric records (2-6 years old, Primary Care Providers only) contain current immunization status.2 Documentation reflects that by the age of 24 months the following vaccines have been administered:
  • Four DTP or DTaP, or an initial DTP or DTaP followed by 3 DTP or DTaP
  • Three IPV
  • One MMR
  • Three or four Hib; if PRP-OMP (PedvaxHIB [Merck]) is administered for the first two doses, a total of three vaccinations are acceptable
  • Three Hep B
  • One Varicella (if no reliable history of pox)
  • Four Pneumococcal Conjugate
This indicator would be "Met" if documentation verifies the immunization was not given due to parental refusal, a child's illness/condition precluding immunization, or previous adverse reaction. The indicator would be "Met" if documentation confirms by date that all expected immunizations not given at this site were administered at another site (e.g., county public health).
Documentation does not reflect that by the age of 24 months the following vaccines have been administered:
  • Four DTP or DTaP, or an initial DTP or DTaP followed by 3 DTP or DTaP
  • Three IPV
  • One MMR
  • Three or four Hib; if PRP-OMP (PedvaxHIB [Merck]) is administered for the first two doses, a total of three vaccinations are acceptable
  • Three Hep B
  • One Varicella (if no reliable history of pox)
  • Four Pneumococcal Conjugate
This indicator would be "Not Met" without documentation to substantiate parental refusal, previous adverse reaction, or illness/condition precluding immunization. Documentation that reflects immunization "through the Department of Public Health" without specific dates is not acceptable.

 

Not applicable if the medical record being reviewed is of a child whose age is younger than two years or older than six years, or the provider site being reviewed is not a PCP site.

8. Documentation of past medical history. Documentation of medical history (MH/CD history for psychiatrists) is present in the medical record. When reviewing medical records of children, this indicator would be considered "Met" if the group being reviewed has apparently cared for the child since discharge from the newborn nursery. This indicator is considered "Met" if documentation reflects the patient's refusal to give a history, the patient is unable to give an accurate history, or if the patient is adopted and does not know his/her family history. Medical history (MH/CD history for psychiatrists) is not documented.

 

Not applicable if the patient has been seen fewer than three times.

9. Documentation of physical examination findings.1 Physical examination findings (mental status exam findings for psychiatrists) are documented at each visit. This indicator is considered "Met" when the purpose of the patient's visit is to discuss treatment options, ancillary test results, etc. (To facilitate comprehension, the reviewer may request a list of abbreviations/symbols and their meanings regarding the physical exam findings.) Physical examination findings (mental status exam findings for psychiatrists) are not documented at each visit. Documentation of vital signs is not adequate without supportive, subjective information. See exceptions under "Met."
10. Documentation of a working diagnosis. Documentation of a diagnosis is present at each visit. If the patient is being seen for a recheck of a previously documented diagnosis, this indicator is considered "Met." A diagnosis is not documented at each visit with the exception outlined in the "Met" column. The sole use of an ICD-9 CM code is not adequate.
11. Documentation of a treatment plan. Documentation of a treatment plan is present following each visit. Examples may include use of medication, ancillary testing, consultation, diet, exercise, and/or a return visit. A treatment plan is not documented following each visit.
12. Supporting documents are filed in the medical record. The results of the care delivered by other providers/ facilities, as directed by the provider(s) being reviewed, are noted in the record. Examples include consultation reports, emergency room visits, external x-ray, and lab reports, etc. (Loose papers and telephone slips are not considered supporting documents.)

The results of care delivered by other providers/facilities, as directed by the physician being reviewed, are not noted in the record.

 

Not applicable if documentation indicates the patient was not referred to another provider/facility for care.

13. Laboratory, x-ray, and consultation reports filed in the medical record are acknowledged by the ordering provider. Laboratory, x-ray, and consultation reports (as directed by the provider[s] being reviewed) are signed, initialed, and/or directly referenced in the progress notes by the ordering provider. For electronic reports, there is an indication of the ordering provider's review. Laboratory, x-ray, or consultation reports (as directed by the provider being reviewed) are not signed, initialed, or directly referenced in the progress notes by the ordering provider.

 

Not applicable if there is no laboratory, x-ray, or consultation reports (directed by the provider being reviewed) filed in the patient's medical record. Any laboratory, x-ray, or consultation reports completed inpatient does not apply to this indicator.

14. All entries in the record contain author identification. The signature, written initials, or a unique electronic identifier of the author is present following each entry. The author's name or written initials following an entry in an electronic record is acceptable. The use of a signature stamp after July 1, 1999, is not acceptable. (Loose papers and telephone slips are not considered an entry.)

Note: Initials must be handwritten. Typed initials are not acceptable.

Signature or written initials of the author is not present following each entry or the entries dated after July 1, 1999, have been signed with a signature stamp.
15. There is a systematic method of documenting preventive health screening and services and are offered in accordance with the organization's guidelines. There is evidence in the medical record of an age/gender appropriate preventive health screening flow sheet/tool, or the office is able to show evidence of a documented process for tracking preventive health screening and services. There is no evidence in the medical record of an age/gender appropriate health screening flow sheet/tool, and the office is not able to show evidence of a documented process for tracking preventive health screening and services.

1Indicator has been suspended from our medical record review, as it has become a standard of practice in physician offices. However, we do reserve the right to add these indicators back into the medical record review audit in the future.

2Indicator 7 is no longer a separate indicator, and has been incorporated into indicator 15. 

 


FacebookTwitterInstagrampinterestLinked InYou Tube