NURS 561 Medical Record Documentation Discussion

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NURS 561 Medical Record Documentation Discussion

NURS 561 Medical Record Documentation Discussion



Medical record documentation is required to record pertinent
facts, findings, and observations about an individual’s health history,
including past and present illnesses, tests, treatments, and outcomes. The
medical record chronologically documents the care of the patient and is an
important element contributing to high-quality safe care.

Discuss your State Board of Nursing nurse practitioner
documentation guidelines and how this can impact your level of reimbursement in
the clinical setting.

The following standards for medical records have been adopted from the National Committee for Quality Assurance (NCQA), and Medicaid Managed Care Quality Assurance Reform Initiative (QARI) as the minimum acceptable standards within most health plans.

1. Organization: Medical records must be organized systematically and uniformly to allow for efficient and rapid review. Papers must be firmly attached. Individual unit medical records are recommended as opposed to family medical records. If family records are utilized, each patient’s component of the record must be clearly distinguishable and organized.

2. Patient Identification: Each page in the medical record must contain the patient name or identification number.

3. Personal/Biographical Data: Personal and biographical data must be noted. This may include address, employer, date of birth, sex, marital status, and home/work telephone numbers.

4. Provider Identification: All entries, including dictation, must be identified by the author (with credentials) and authenticated by his or her entry. Authentication may include signatures or initials, thereby verifying that the report is complete and accurate.

5. Entry Date: All entries must be dated and all records must be complete within thirty (30) days of discharge or, if in the outpatient setting, within thirty (30) days of the office visit.

6. Legible: The medical record must be legible to someone other than the writer.

7. Problem List: Significant illnesses and medical conditions should be indicated on the problem list. If the patient has no known medical illness or condition, the medical record must include a flow sheet for health maintenance.

8. Allergies: Allergies/no known allergies (NKA) must be documented in a uniform location on the medical record. Medication allergies and other adverse reactions must be listed if present. List no known allergies (NKA) if applicable.

9. Past Medical History (for patients seen three or more times): Past medical history should be easily identifiable and include serious accidents, operations, illnesses, and familial/hereditary disease.

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10. Smoking/Alcohol/Substance Use (for patients seen three or more times): Notation concerning cigarette, alcohol, and substance use.

11. Physical Exam (complete): All body systems to be reviewed within two years of the first clinical encounter.

  • Height, weight, blood pressure, and temperature must be documented on the initial visit.
  • History and Physical: Subjective and objective information is obtained and noted for the presenting complaints.
  • Working Diagnosis: Working diagnosis is consistent with findings (physician’s medical impression).
  • Plan/Treatment: Documentation of plan of action and treatment are consistent with diagnoses.
  • Patient Education/Instructions: Documentation present as applicable.
  • Consults/X-ray/Lab/Imaging Reports/ Referrals/Records: Reports are filed in the medical record and initialed by the primary care physician, thereby signifying review. Consultation and abnormal lab imaging study results should have an explicit notation in the medical record of follow-up plans and notification to patient of all results (i.e., positive and negative). Referrals, past medical records, and hospital records (e.g., operative and pathology reports, admission and discharge summaries, consultations, and ER reports) should be filed in the medical record.
  • Follow-up/Return Visits: Encounter forms or notes have a notation concerning follow-up care, call or visit. Specific time to return is noted in weeks, months, or as necessary. Unresolved problems from previous visits are addressed in subsequent visits.
  • Medical Care/Services/Consults: A general overview of medical care, services and consults ordered will be reviewed. If any potential quality issues are identified, the reviewer should refer to the practice or health plan’s designated Medical Director for further direction.
  • Immunization Record Must Indicate:
  • Tetanus/diphtheria immunization status for patients 21 and older
  • Influenza/pneumococcal immunization status for patients 65 and older
  • Influenza, pneumococcal, and/or hepatitis B immunization status for high risk patients 21 and older
  • Documented immunization record for patients under 21. If there is no record, there must be documentation regarding immunization status (e.g., “Up To Date” (UTD)), stating who reported the status and that a copy was requested for the medical record.
  • Preventive Services (for adult patients seen three or more times): Record should indicate preventive services are offered according to defined Adult Screening Guidelines for Asymptomatic Men and Women. (For patients under 21, preventive health services must be provided according to the state’s mandated periodicity schedule.)
  • Advance Directives (for patients 21 and older only): There should be evidence that the patient has been asked if he or she has an advance directive (written directions about their health care decisions). Yes/no response should be documented. If the response is “yes,” a copy must be included.

To be compliant with HIPAA, providers should make reasonable efforts to restrict access and limit routine disclosure of protected health information (PHI) to the minimum necessary to accomplish the intended purpose of the disclosure of member information.

If a Martin’s Point plan member changes his/ her PCP for any reason, the provider must transfer a copy of the member’s medical record to the member’s new PCP at the request of the plan or the member. The participation agreement states whether the original or a copy of the medical record must be sent. If a provider terminates plan participation or service to our member, the provider is responsible for transferring the member’s medical records. Charges for copying medical records are considered a part of office overhead, and copies are to be provided at no cost to members and Martin’s Point, unless state or federal regulations stipulate differently.

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