Ambulatory Medical Record Documentation Standards

As health care professionals, you know the medical record communicates pertinent information about your patient's past medical treatment, past and current health status, and current and future treatment needs and plans. Whether electronic or hardcopy, medical records must contain well-documented, clearly understood, updated and complete information to ensure continuity of care, and to promote efficient, effective quality care. Achievement of these goals is facilitated when you and your staff consistently practice accepted standards for medical record documentation.

Western Health Advantage (WHA) is required by state and federal regulatory bodies, and by the National Committee for Quality Assurance (NCQA) to monitor medical records of our network physicians to ensure ongoing documentation compliance. Medical record files are audited at least every 2 years by nurses from either your group or by WHA to ensure compliance, and to identify educational needs and opportunities for improvement. An overall score of 90% for the six "core" elements listed below must be achieved to pass the medical record audit. If the initial audit score is below 90% you will be asked to submit a written corrective action plan (CAP) to your group or WHA, which addresses any deficiencies. Once the CAP is accepted and approved, your files will be re-audited within 3 months and subsequently as needed, until a 90% passing score is achieved.

Western Health Advantage recognizes your ongoing efforts to provide quality care and services to our members, and we thank you for helping the Plan to achieve our quality improvement goals in these areas.

For copies of WHA's or your group's Ambulatory Medical Record Audit policies and tools, please contact your group's Medical Management Department. In the meantime, please take a few moments to review the following documentation guidelines and apply them to your daily practice.

"Core" Required Elements Reviewed During Ambulatory Medical Record Audits

• Health history (current)
• Problem list (routinely updated)
• Medication allergies and adverse reactions (routinely verified-dated)

Appropriate treatment

• Plans for further treatments

Guidelines for Medical Record Documentation

The following are commonly accepted standards for documentation in medical records. NCQA and WHA require auditors to review at a minimum, the six elements listed above and as noted below with asterisks:

1. Each page in the record contains the patient's name or ID number.
2. Personal biographical data include the address, employer, home and work telephone numbers and marital status. (verify and update routinely)
3. All entries in the medical record contain the author's identification. Author identification may be a handwritten signature, unique electronic identifier or initials.
4. All entries are dated.
5. The record is legible to someone other than the writer. A second surveyor examines any record judged to be illegible by one physician surveyor.
6. *Significant illnesses and medical conditions are indicated on the problem list (routinely updated with dates).
7. *Medication allergies and adverse reactions are prominently noted in the record. If the patient has known allergies or history of adverse reactions, this is appropriately noted in the record.
8. *Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses.
9. For patients 14 years and older, there is appropriate notation concerning the use of cigarettes, alcohol and substances (for patients seen three or more times, query substance abuse history).
10. The history and physical examination identifies appropriate subjective and objective information pertinent to the patient's presenting complaints.
11. Laboratory and other studies are ordered, as appropriate.
12. Working diagnoses are consistent with findings.
13. Treatment plans are consistent with diagnoses
14. Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls or visits. The specific time of return is noted in weeks, months or as needed.
15. Unresolved problems from previous office visits are addressed in subsequent visits.
16. Review for underutilization and over-utilization of consultants.
17. If a consultation is requested, is there a note from the consultant in the record?
18. Consultation, lab and imaging reports filed in the chart are initialed by the practitioner who ordered them to signify review. Review and signature by professionals other than the ordering practitioner do not meet this requirement. If the reports are presented electronically or by some other method, there is also representation of review by the ordering practitioner. Consultation and abnormal lab and imaging study results have an explicit notation in the record of follow-up plans.
19. There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.
20. An immunization record for children is up-to-date or an appropriate history has been made in the medical record for adults.

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