Practitioner documentation review standards

Identification

  • Name (O,N)
  • Address (N)
  • Home phone (N)
  • Date of birth/age (O,N)
  • Gender (O)
  • Next of kin/emergency contact with phone number (O)
  • Employer (N)
  • Work phone (N)
  • Marital status (N)

These standards provide current information on a patient. All patient charts must include the listed personal/ biographical data.

Patient name or ID number on each page
(N)

The patient who received the documented care must be easily identified on each page.

Medication allergies or NKA
(O,N)

Allergies, or NKA if no allergies to medications exist, should be clearly and easily identified on each patient's record. This aids in the prescription of medications in a therapeutically safe and effective manner.

Health status

Annually document and/or report, when applicable, ICD-9 status codes to identify that patient is a carrier of a disease with no current symptoms and/or has lingering effects of a past condition or past treatment. Get details on health status codes.

Problem list completed
(N)

Significant illnesses and medical conditions need to be clearly identified in each patient's record. Maintaining problem lists enhances patient information from which a provider can effectively develop a treatment plan.

History

Medical (E,O,N)
Family (E,O)
Social (E,O,N)

All patients need to have documentation of medical, family and social histories in their medical records to provide a database from which a planned course of treatment and care can be developed. Past medical history 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. For all patients 14 years and over, notation concerning use of cigarettes (12 years and older), alcohol, substance abuse and sexually-transmitted diseases is present. It is recommended that patient histories be routinely updated with biennial physicals. If there is no change, a note to this fact can be made on the original history form and dated. The history form should be initialed and dated when it is reviewed or updated.

Interval history
(E)

An interval history is a brief or detailed summary of events since the last Well Child visit. For a child without sick visits, documentation such as "no problems" is adequate. For a child with sick visits, documentation such as "4-year-old with resolving otitis" is acceptable.

Ancillary reports
(O)

Ancillary reports (such as physical therapy, outpatient treatment, speech, dietitian, employer, school, home care, emergency room, etc.) provide information to enhance continued development of treatment plans.

Inpatient discharge summaries filed chronologically
(O)

Knowledge of inpatient treatment provided enhances the continued development of treatment plans.

Consultative report for each referral
(O,N)
Communication form from BH provider referral
(N)

Each referral to another provider requires documentation of the evaluation and/or treatment performed to enhance continued development of treatment plans. Physicians must date and sign or initial to indicate their review.

For members receiving Behavioral Health services, the communication form or documentation regarding the referral for services should be in the record.

Physical exam offered/ completed
(E,O,N)

Through complete physical examinations, providers can encourage health maintenance and/or preventive health measures. Refer to Priority Health's Preventive Health Care Guidelines for appropriate exam frequency and prevention screening. If a member is seen for an illness or injury and has not had a physical exam, a recommendation that the patient return for an exam should be made and documented in the record.

Documentation of counseling for identified risk factors
(N)

As health risk factors are identified for each patient, appropriate discussions or counseling of the potential effects of those risks is recommended.

Smoking history assessed
(H)
Smoking cessation counseling
(H)

As health risk factors are identified for each patient, appropriate discussions or counseling of the potential effects of those risks is recommended. Smoking history should be assessed at every visit. If the patient is a smoker, smoking cessation should be addressed at every visit (along with vital signs) and documented.

Documented each visit

Blood pressure as medically necessary
(E,PH)

Blood pressure measurement is an essential indicator of cardiovascular health. Patients seen for episodic care only should have their blood pressure checked periodically.

Children must have blood pressures taken at every physical, beginning at age 3. Either the blood pressure or an indication that it was attempted must be documented.

Chief complaint/reason for visit
(O,N)

To provide a database from which a planned course of treatment and care can be developed.

Physical exam findings
(N)

Physical exam findings must be documented in the record.

Diagnosis/medical impression
(N)

A diagnosis/medical impression consistent with the physical exam findings must be documented in the record.

Studies ordered (lab, X-ray, EKG)
(N)

To provide a database from which a planned course of treatment and care can be developed. There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure.

Therapies administered & prescribed
(N)

To provide a database from which a planned course of treatment and care can be developed. Treatment plans are consistent with diagnosis.

Recommendations/ instructions/ interpretive conference
(E,N)

An interpretive conference is performed at each Well Child visit explaining the pertinent findings of the examination. Health education is designed to heighten a recipient's awareness and knowledge regarding the prevention of accidental injury or poisoning, and disease or disability caused or aggravated by personal health practices. Documentation may reflect whether or not the parent/guardian asks questions and appropriate information is given by the practitioner.

Evidence of follow-up
(N)

Encounter forms or notes have a notation regarding follow-up care, calls, or visits. The specific time of needed follow-up care is noted in weeks, months, or as needed.

Anticipatory guidance
(E)

Anticipatory guidance includes upcoming milestones and expectations based on age. Documentation of discussions, counseling, and education regarding age appropriate concerns regarding growth and development, problem prevention, and safety issues. Medicaid only.

All entries are legible
(N)

All entries in the patient record must be legible to someone other than the writer.

All entries are dated & signed
(O,N)

Physicians and staff need to date and sign, or initial, all entries in patient records. Dated and signed entries serve to:

  • Prevent potential confusion over entered data should questions arise regarding authenticity of the documentation in the medical record
  • Validate the source of information in cases where transfer of records becomes necessary.

If initials are used instead of signatures, a signature register needs to be kept on file. 

If an electronic charting system is in use, the electronic signature must be password-protected. 

For Medicare patients, a signature stamp is not acceptable.

Procedure & surgical notes

Detail(s) support the procedure/service
(CPT or HCPCS code) performed

Documentation within the operative note should resemble the lay description of the CPT or HCPCS code selected. Notes should clearly support each service performed by describing the approach, anatomical site(s), and surgical techniques used. Documentation for repeated procedures on different anatomical sites (fingers, toes, limbs), spinal levels, or paired organs should clearly detail each distinct procedure and support its medical necessity.

Lab & radiology reports

Tetanus (O,N)

All adult records should document tetanus immunization status. If the status is unknown and not easily obtained from a previous physician, the Centers for Disease Control recommends that the tetanus booster be given. Tetanus boosters should be updated every ten years and assessed by the third visit or with the physical exam.

Pediatric records

Immunizations
(E,O,N)

All pediatric records should include a completed immunization record. Immunizations should be assessed at every opportunity.

Head circumference
(E)

Height and weight
(E)

An indicator of normal growth and development. Medicaid only.

Pediatric sensory screening

Hearing
(E)

Assess hearing to determine any abnormalities that would need intervention. Any age-appropriate subjective or objective hearing test is acceptable. Medicaid only.

  • Startling or clapping is acceptable with young children.
  • For children 6 months to 2 years, any indication that the child is hearing normally is acceptable, such as "follows two-word commands", "points to a named picture", "points to body part", "understands commands", etc.

Vision
(E)

Assess vision to determine any abnormalities that would need intervention. Any age-appropriate subjective or objective vision test is acceptable. Medicaid only.

  • Documentation such as "follows with eyes" or "tracks" is appropriate for young children.
  • For children 6 months to 2 years, any indication that the child is seeing normal is acceptable, such as "points to named picture", "points to body part", "scribbles", "kicks ball", etc.

Developmental assessment (E)

Developmental assessment is an indicator of normal development. A developmental assessment may include a listing of milestones achieved, a list of tasks the child is able to perform and/or an assessment of gross and fine motor skills. Developmental assessment could include intellectual, psychosocial, and cognitive development measures as well as speech and language assessments. Medicaid only.

Pediatric assessment & procedures

Dental inspection
(E)

A description of dentition or condition of primary or permanent teeth constitutes a dental inspection. Gum description for babies is acceptable.

A complete dental inspection should be performed and documented. A referral to a dentist for further treatment, should be made as needed. Medicaid only.

Nutritional assessment
(E)

Adequate nutrition is important for normal growth and development. Nutritional assessment may include dietary intake, eating habits, and/or discussion of food choices. Medicaid only.

Blood lead level
(E)

  • Risk assessed
  • Lab performed

Lead poisoning is considered the most important environmental health problem for young children. The prevention of lead poisoning is accomplished through the removal of environmental lead and lead screening. Leas exposure may occur in any demographic grup, but the two variables highly associated with lead exposure are 1) living in a home built before 1950 and 2) low income level.

This must be documented for all Medicaid members between 12 and 24 months of age.

Hemoglobin/ hematocrit
(E)

Hemoglobin and hematocrit screening is an indicator of many disease states. Medicaid only.

Sickle cell
(E)

If the child was born in a Michigan hospital on or after October 1, 1987, the sickle cell test is not required. For children with all or some black heritage, the test is required prior to the child's 21st birthday unless electrophoresis for sickle cell was done when the child was at least six months of age, the results are known to the parent, and are documented in the patient's history. Medicaid only.

Tuberculin test
(E)

  • Risk assessed
  • Lab performed

Risk assessments focus on whether the child has been exposed to a relative, playmate, or other acquaintance with inactive or active TB. Medicaid only.

Urine test
(E)

Urine screening is an indicator of many disease states. A urine screen is to be performed at 5 years of age and for any sexually active male or female. Medicaid only.

Injury prevention
(E)

Education needs to be performed at each Well Child visit.

Sleep position counseling
(E)

Educate parents/guardians to position infants on their backs to sleep through 6 months of age to decrease the probability of Sudden Infant Death Syndrome (SIDS).

Violence prevention
(E)

Education needs to be performed at each Well Child visit.