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Medicare - Credentialing & Recredentialing

Standards For Performing Medical Record Review (Practitioners Only)

A. General Standards
1. Patient's records must be easily retrieved and accessible.
2. Patient records must be stored in a confidential area and only those office staff members whose job descriptions necessitate access to patient information should have authorization to access patient records.
3. Office staff must obtain signed authorization prior to releasing patient records in accordance with HIPAA regulations.
4. Medical information must be current, detailed and organized.
5. Evidence that office staff receives periodic training in confidentiality of member information.
6. The physician office should have 24 hour call-in capability (answering service/machine with directions to call beeper).

Chart Review Standards

1.	Legibility: The record must be readable and the contents comprehendible.
2.	Page Content: Each page/entry requires the patient name or identifier, date of entry, and entry author signature, as appropriate.
3.	Problem List: A problem list with the patient’s ongoing, chronic medical/psychological conditions and/or significant illnesses must be maintained in the patient record. If there are no identified significant problems, there must be some notation in the progress notes stating that this is a well child/adult.
4.	Allergy Documentation: Allergies and adverse reactions must be specifically and prominently documented in the patient record on all members age two (2) and older. If a patient is noted to have no allergies, this fact must be documented prominently in the patient record (i.e., NKA or no known allergies, NKDA or no known drug allergies).
5.	Past Medical History: Charts should include notation of physical exams, necessary treatment and possible risk factors relevant to the treatment.
6.	Documented Smoking, Alcohol and Substance Abuse: An assessment of smoking or alcohol or substance abuse, must be documented on the medical record on all patients twelve (12) years old and older.
7.	Confidentiality Clinical Information: Clinical information relevant to the patient should be contained in the record or in a secure computer system, stored/accessed in a non public area, and available upon identification of an approved person.
8.	Labs, x-rays, and other diagnostic tests are initiated and noted in record: All lab, x-ray, and other diagnostic tests must be initialed by the physician or remarks noted in the progress section of the patient record to indicate that reports have been reviewed, including inpatient labs.
9.	Presenting complaints, Diagnoses, Abnormal Labs, X-ray and Consult Results have a Plan for Follow-up Treatment Documented in the Patient Record: All complaints, diagnoses, and abnormal reports must have documentation regarding follow-up plans for continued evaluation and/or resolution/treatment of abnormal results.
10.	Immunization records: Immunization records must be easily accessible in the patient record.
11.	Preventive Screening: There is evidence that preventive screening and services are offered.
12.	Medication List: There is a medication list, which includes dosages and dates for initial and refill prescriptions. Notation in the progress note is acceptable.
13.	Advance Directives: There should be documentation in the records of all patients 45 years or older that advance directives have been discussed. If the patient chose to make an advance directive (in the past or present), there should be a copy of it in a prominent part of the member record. Notation should be made if the member does not wish to make an advance directive.
14.	Consultation Requested: All requested consults must have return reports from the requested consultant or a phone call follow-up must be noted by the PCP in the progress note. Consultation Follow-up: All consults must have follow-up notation by the PCP in the progress note, treatment plan changes or a response letter, if further action is required.
15.	Hospitalization Summary: All hospitalizations must have a discharge summary from the hospital or notation in the progress note. Hospitalization Follow-up: All hospitalizations must have notation by the PCP if further action is required.
16.	Home Health or Hospice Care Referral: All referrals to home health care or hospice care must have a copy of the nursing reports of patient status present in the record or notation of telephone communication in the PCP’s progress notes from the home care or hospice care service. Home Health Care/Hospice Care Follow Up: All home health care or hospice care follow-up must have notation by the PCP if further action is required.
17.	Measurement of Body Mass Index (BMI) Recorded: Notation of BMI should be recorded on the medical record in conjunction with a health maintenance visit.

Note: We have provided you with sample Patient Summary and Medication charts are available online.

PPM/1.11

Providers

Medicare Physician & Provider Manual

Headlines

Medicare - Credentialing & Recredentialing

Standards For Performing Medical Record Review (Practitioners Only)