GUIDELINES FOR MEDICAL RECORD DOCUMENTATION
Consistent,
current and complete documentation in the medical record is an essential
component
of
quality patient care. The following 21 elements reflect a set of commonly
accepted standards
for
medical record documentation. An organization may use these elements to develop
standards
for
medical record documentation.
NCQA
considers 6 of the 21 elements as core components to medical record
documentation. Core elements are indicated by an asterisk (*).
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.
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.
*6. Significant illnesses and medical
conditions are indicated on the problem list.
*7. Medication allergies
and adverse reactions are prominently noted in the record. If the
patient has no 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 12 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, regarding follow-up care, calls or
visits,
when indicated. 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.
There is review for under - or overutilization of consultants.
17.
If a consultation is requested, there a note from the consultant in the record.
18.
Consultation, laboratory 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
laboratory
and imaging study results have an explicit notation in the record of followup
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).
21.
There is evidence that preventive screening and services are offered in
accordance with
the organization’s practice guidelines.
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