2008 Medical Record Review Standards

Complete and consistent documentation in patient medical records is an essential component of quality patient care. AmeriHealth Mercy adheres to medical record requirements that are consistent with national standards on documentation. AmeriHealth Mercy audits the medical records of PCP, OB/GYN and high-volume specialty physicians offices using these standards. The following is a list of our standards:

1. Elements in the medical record are organized in a consistent manner, and the records are kept secure.
2. Patient’s name or identification number is on each page of record.
3. Entries are legible.
4. All entries are dated.
5. All entries are initialed or signed by the author.
6. Personal and biographical data are included in the record.
7. Current and past medical history and age-appropriate physical exam are documented and included serious accidents, operations and illnesses.
8. Allergies and adverse reactions are prominently listed or noted as “none” or “NKA.
9. Information regarding personal habits such as smoking and history of alcohol use and substance abuse (or lack there of) is recorded when pertinent to proposed care and/or risk screening.
10. An updated problem list is maintained.
11. There is documentation of discussions of a living will or advance directives for patients 65 years of age or older.
12. Patient’s chief complaint or purpose for visit is clearly documented.
13. Clinical assessment and/or physical findings are recorded. Appropriate working diagnoses or medical impressions are recorded.
14. Plans of action/treatment are consistent with diagnosis.
15. There is no evidence the patient is placed at inappropriate risk by a diagnostic procedure or therapeutic procedure.
16. Unresolved problems from previous visits are addressed in subsequent visits.
17. Follow-up instructions and time frame for follow-up or the next visit are recorded as appropriate.
18. Current medications are documented in the record, and notes reflect that long-term medications are reviewed at least annually by the practitioner and updated as needed.
19. Health care education provided to patients, family members or designated caregivers is noted in the record and periodically updated as appropriate.
20. Screening and preventive care practices are in accordance with the AmeriHealth Mercy Preventive Health Guidelines.
21. An immunization record is up to date (for members 21 years and under) or an appropriate history has been made in the medical record (for adults).
22. Requests for consultations are consistent with clinical assessment/physical findings.
23. Laboratory and other studies are ordered, as appropriate.
24. Laboratory and diagnostic reports reflect practitioner review.
25. Patient notification of laboratory and diagnostic test results and instructions regarding follow-up, when indicated, are documented.
26. There is evidence of continuity and coordination of care between primary and specialty care practitioners or other providers.