1 = Never (none) / No
2 = Occasionally (25%)
3 = Generally (50%)
4 = Frequently (75%)
5 = Always (100%)
N/A= Non-applicable
To pass, physicians must score at least 85%; physicians who score between 66% and 84% will be instructed/receive an accounting of their deficiencies. Physicians scoring 65% or less will also be instructed/receive an accounting of their deficiencies, and will also have to submit a corrective action plan that outlines how they plan to improve.
Please note: if a record is judged to be illegible, the QI Coordinator must notify the physician, and the physician must send to Empire legible notes that are either typewritten, or printed.
Record Guidelines:
Consistent and complete documentation in the medical record is an essential component of quality patient care.
Each page in the record contains the patient’s name or ID number.
Personal/biographical data includes the:
Address
Employer
Home telephone number
Work telephone number
Marital status
Gender
Emergency contact
All entries in the medical record have author’s identification.
All entries are dated.
Significant illnesses and medical conditions are prominently documented on the problem list.
Medication list is current and prominently documented.
Medication allergies and adverse reactions to medications are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is prominently noted as well.
Past medical history 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 as well as those components referenced in the Pediatric Health Guidelines.
The history and physical exam identifies appropriate subjective and objective information pertinent to the patient’s presenting complaints.
Working diagnosis is consistent with findings.
Treatment plans are consistent with diagnosis.
Patient education / instruction is appropriate to diagnosis.
Unresolved problems from previous office visits are addressed in subsequent visits.
Encounter forms or notes have a notation regarding follow-up care, calls, or visit.
Review for underutilization and over utilization of consultants.
If a consultation is requested, is there a note from the consultant in the record? This includes referrals for behavioral health services.
Consultations, lab reports, and imaging reports filed in the medical record are initialed by the ordering practitioner to signify review. Review and signature by professionals other than the ordering practitioner do not meet this requirement. A stamp, highlighting of results, or a check mark on the report is not sufficient. If the reports are presented electronically, or by some other method there is also representation of physician review. Consultations, abnormal labs and imaging study results have an explicit notation in the record of follow-up plans.
Hospital admissions, SNF placement, Home Care services, and/or freestanding surgical center services are reflected appropriately in the medical record.
Advanced Directives must be placed in a prominent part of the medical record. All members, aged 65 and older, should have prominent documentation of whether or not the member has executed an Advanced Directive.
There is no evidence that patient is placed at inappropriate risk by the management of diagnostic or therapeutic procedures, including over utilization or underutilization of services.
Capillary or venous blood test for lead by the end of the 25th month of life.
