Indicator Guidelines
1. The medical records reflect all aspects of patient care including the following:
A. Member identification
The member's name, date of birth, medical record number or AHCCCS identification number is on all pages with entries.
B. Identifying demographics
The member's name, address, telephone number, AHCCCS identification number, gender, age, date of birth, marital status, next of kin, and if applicable, guardian or authorized representative, should be documented in a consistent location.
C. Current medications noted
A completed medication list with dates of entry should be found which summarizes all current, chronically prescribed medications. This information will be found in a consistent location in the medical record.
D. Current problem list
A completed problem list with dates of entry should be found which summarizes all significant illnesses, medical conditions, past surgical procedures, or chronic health problems and is updated as new problems are encountered, as documented in the progress notes. This information will be found in a consistent location in the medical record.
2. The medical record reflects the following for the last visit in the study period:
A.1. Provider, signature identifiable
The provider identifiably signs all entries of service provided to a member. If a typed or stamped signature is used, it must be accompanied by the provider's initials/signature. If recorded electronically, the author must be identified.
A.2. Four digit ID number present
For UPI providers only, a four digit ID number accompanies all signatures for entries of service provided to a member.
A.3. Entries legible
The record is legible to someone other than the author. The reviewer must be able to ascertain the essential data on an entry and the resulting plan of care.
A.4. Entries dated All provider entries of service provided to a member are dated.
A.5. Co-signature, as appropriate
When a health care assistant (e.g. students and unlicensed assistive personnel) provides services to a member, their entries are co-signed by a licensed professional who is authorized by the licensing authority to provide supervision. Residents must have a co-signature by an attending provider.
B.1. PCT, signature identifiable
The patient care team member must identifiably sign their first initial and last name on all entries of service provided to a member. If recorded
electronically, the author must be identified.
B.2. Title present
A title accompanies all signatures for patient care team member entries of service provided to a member (e.g. MA, LPN, RN).
B.3. Entries legible
Patient care team member entries are legible to someone other than the author. The reviewer must be able to ascertain the essential data on an entry.
B.4. Entries dated
All patient care team member entries of service provided to a member are dated.
C.1. Allergies/adverse events
Medication allergies and adverse drug reactions must be noted on the progress note for each visit. Absence of allergies should also be documented (e.g. NKDA).
Indicator Guidelines
C.2. Positive symptoms documented
Positive symptoms for each medication allergy or adverse drug reaction are documented (e.g. PCN - hives).
D. Current problem and exam
Each progress note should contain the chief complaint or purpose for the visit, and the physical exam findings.
E. Plan of treatment
The progress note should include a plan of care which addresses all treatments, and instructions to the patient, as applicable.
F. Follow up visit need documented
A scheduled return visit (in days, weeks, months or PRN) is documented for each encounter.
3. The following should be documented for members who have had at least three visits:
An initial history for all members should include family medical history (a record of the state of health and medical history of members in the immediate family), social history (family situation), and preventative lab screenings. The initial history for members under age 21 should also include prenatal care (documentation of mother receiving prenatal care and/or complications of pregnancy) and birth history. This can be in the form of a progress note or a history form completed by the patient. If there is a past history in the chart that was completed while the patient had another form of insurance, the indicator will be met.
B. Past medical hx is noted
A past medical history should be found for all members (for the previous 5 years if available). It should include disabilities, previous illnesses or injuries, hospitalizations, surgeries and emergencies. This can be in the form of a history form completed by the patient, a progress note or a detailed problem list.
C. Grava/para > 14 yrs.
The number of pregnancies and live births are documented for females 15 years of age and older.
D. Family planning services (15-55 yrs.)
Annual notice verbally or in writing of the availability of family planning services for men and women age 15-55 (inclusive) is documented. Any notation regarding any form of birth control is acceptable. Mark N/A if a women has had a hysterectomy or a tubal ligation or if a man has had a vasectomy
E. Immun. rcds. (pediatric) < 21 yrs.
An immunization record is present for children under 21 years, and vaccine name, dose and route is documented. Documentation of "up to date" (UTD) does not meet this indicator.
F. Immun. Rcds. (adult) > 20 yrs.
An appropriate immunization history has been made in the medical record for adults 21 years of age and older (Td, influenza, pneumococcal 65 years of age and older).
G. Substance use/abuse hx > 15 yrs.
For members 16 years or age and older, there is documentation addressing the use of alcohol, tobacco and substances.
H. Dental history < 21 yrs.
A dental history, if available, is present for all members under 21 years of age. Evidence of dental discussion (e.g. gums checked, dental caries noted, referral given to dentist, etc.) is documented.
I. Advance directives documented > 20 yrs.
There should be documentation as to whether or not an adult member 21 years of age and older has completed advance directives.
EPSDT Tracking Forms are to be used by providers to document all age specific, required information related to EPSDT screenings according to the following minimum service intervals: 2-4 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 3 years, 4 years, 5 years, 6 years, 8 years, 10-13 years, 14-17 years, and
Indicator Guidelines
K. PEDS Tool - NICU grads
PEDS Tools are to be used by trained providers to evaluate all NICU graduates born after 1/1/06.
4. Responses for the following should be based on materials received since the last recredentialing cycle/medical record documentation audit:
A. Diagnostic information noted
All laboratory tests and screenings, radiology reports, physical exam notes should show PCP's initial or indication that the physician has reviewed the results.
B. Consult/referral info noted
All reports from referrals, consultations and specialists should show PCP's initial or indication that the physician has reviewed the results.
C. Emergency/UC reports noted
All emergency/urgent care reports should show PCP's initial or indication that the physician has reviewed the results.
D. Hospital discharge noted
All hospital discharge summaries should show PCP's initial or indication that the physician has reviewed the results.
E. Behavioral health services noted
All behavioral health services provided, if applicable, should show PCP's initial or indication that the physician has reviewed the results.
F. Release of information documented
Signed release of information should be documented. This can be in the form of present facility requests to send or receive materials as well as past facility requests. HIPAA consent forms that specifically address release of information can be used in conjunction with materials sent or received for adequate documentation. Notation of follow through should be documented (e.g. date information released and signature of staff member showing completion).
G. Communication between providers
Documentation that reflects diagnostic, treatment and disposition information (including records received from previous health care providers) related to a specific member was transmitted to the PCP and other providers as appropriate to promote continuity of care and quality management of the member's health care.
H. Notification to BH provider if change in health status or new Rx prescribed.
Documentation that reflects communication between the PCP and BH provider related to a change in the member's health status or a new medication
J. Referrals to low/no cost primary care services as appropriate
There is evidence in the medical record that the provider has referred the member to low/no cost primary care services as appropriate. (Members who are losing AHCCCS/SOBRA eligibility)
Revised 9/08
Policy Number: QM102