April 2010
Medical record documentation standards audit
Annually, Medicaid requires health plans to audit provider medical records to ensure compliance with documentation standards. Asuris recently conducted this review in conjunction with the Medicare risk adjustment record review to consolidate medical record chart requests.
The 2009 medical record review indicated that documentation related to counseling patients for smoking cessation was the area in greatest need of improvement. Providers contracted with Asuris provided counseling to smokers 36% of the time.
The 2010 chart review scheduled for later this year for medical record documentation, focuses on the following six standards with a goal of 80% compliance:
- Are significant illnesses and medical conditions documented on a problem list?
- Are medication allergies and adverse reactions, or the lack of allergies (NKA) prominently displayed in a designated location on the chart?
- For adult patients (18 years of age or older), does the record document in a prominent place whether or not they have executed an advance directive?
- If an adult patient has an advance directive, is there a copy of the directive in the record?
- Is smoking history documented?
- If patient is a smoker, did provider counsel to stop?
We will communicate to you once the 2010 medical record review has been scheduled.
We appreciate your efforts in improving documentation and hope you find this specific information helpful in complying with Medicaid compliance criteria. Thank you for your cooperation and ongoing effort.