Wellmark, Inc. believes that the medical record is the single key source of information pertaining to the patient’s health status and needs. Thus 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 itself should contain the information as outlined below and on the subsequent pages. The following highlighted medical record indicators (2, 4, and 9) have been currently suspended from our medical record review. As they have become a routine standard of practice in physician offices, it is felt that it is no longer necessary to audit them. We do not anticipate this will change; however, we do reserve the right to add these indicators back into the medical record review audit, in the future. Also, medical record indicator 7 is highlighted as it is no longer a separate indicator. It has now been incorporated into indicator 15.
| 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. |
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.
Problem List/Past Medical History Medical Record Keeping Aid
You will need Adobe Acrobat Reader to open this form.
Click the icon to download it free.  |
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.
|
| 4. All entries are dated.
|
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.
In order 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 are 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. |
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; and
- Three or four Hib. If PRP-OMP (Pedvax HIB [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)
- 4 Pneumoccal 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; and
-
Three
or four Hib. If PRP-OMP (Pedvax HIB [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)
-
4 Pneumoccal 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 less than two or greater than six years or
the provider site being reviewed is not a PCP site. |
| 8. Documentation of past medical history.
Problem
List/Past Medical History Medical Record Keeping Aid
You will need Adobe Acrobat Reader to open this form.
Click the icon to download it free.
|
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 less than three times.
|
| 9.
Documentation of
physical examination findings. |
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.
(In order 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 preventative 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 preventative health screening flow sheet/tool or the office is able to show evidence of a documented process for tracking preventative 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 preventative health screening and services. |
Measures are based on twelve months of documentation,
unless otherwise indicated in the measure, starting from the date of
the review.
