2002 and 2003 Medical Record Review
Annually, nurse auditors from the Quality Management Department of UniCare Health Plans of the Midwest, Inc. (UniCare HMO) conduct medical record audits on PCP records to assess compliance with the medical record standards. In 2002 the medical records of over 350 PCPs were reviewed. The audit results of significance are as follows:
- <1% of PCPs had an overall score of <80% (<1% failure rate on all elements)
- 12% of PCPs had a score of <80% on the Continuity and Coordination of Care (CCOC) elements
- 15% of PCPs had a score of <80% on the Patient Safety elements.
The CCOC element that most commonly led to failure was lack of PCP initialed labs, consults and imaging studies.
The most common Patient Safety element that led to failure was lack of patient name or ID number on front and back of pages containing clinical information.
Continuity and Coordination of Care and Patient Safety are critical aspects of the delivery of medical care. All practitioners are urged to review current office procedures and practice and if indicated, consider implementing alternative procedures, practices, forms, etc. that will help contribute to safe delivery of care.
The audit results also provided interesting findings related to medical record keeping and confidentiality. Findings indicated that 27.5% of PCPs reviewed did not have a formal written medical record confidentiality policy. With the advent of HIPAA, it is anticipated that compliance with this aspect of the UniCare Medical Record Standards will improve.
During the third and fourth quarter of 2003, PCPs who have been in the HMO network for at least two years and have 100 or more UniCare HMO members in their panel may be contacted by nurse auditors from Quality Management to schedule a medical record audit. A sample of 10 medical records will be audited for compliance with the medical record documentation standards below. Additionally each office site will be audited for compliance with the three availability and confidentiality standards. The medical record review standards are as follows.
UniCare 2003 Medical Record Review Standards
Medical Record Documentation Standards
- Each page of the medical record contains the patient's name (front and back.)
- All entries in the medical record are indelibly added, dated, and contain the author's identification, which may be a handwritten signature, unique electronic identifier, or initials.
- The medical record is legible to someone other than the writer. A second reviewer examines any record judged to be illegible.
- Chronic medical conditions (for patients seen 3 or more times) are indicated on a problem list.
- Medication allergies and adverse reactions are prominently noted in the medical record.If the patient has no known allergies or history of adverse reactions, this is noted in the medical record.
- Past medical history (for patients seen 3 or more times) is easily identified.
- Reports on consultation, lab and imaging ordered by the PCP and filed in the medical record, are initialed by the PCP to signify review. If reports are presented electronically or by some other method, there is representation of review by the PCP.
- Consultations ordered by the PCP that indicate a need for follow-up and lab and imaging studies ordered by the PCP where the results were abnormal have an explicit notation by the PCP in the medical record for follow-up plans.
Select Aspects of Confidentiality and Availability Standards
- Patient medical records are easily retrievable by all staff for office visits and telephone inquiries.
- Patient medical records are protected from public access.
- Practitioner offices have a formal written medical record confidentiality policy.
