| Standard |
Rationale |
| IDENTIFICATION |
Name (O,N)
Address (N)
Home Telephone Number (N)
Date of Birth or Age (O,N)
Gender (O)
Next of Kin/Emergency Contact with Telephone Number (O)
Employer (N)
Work Telephone Number (N)
Marital Status (N) |
These standards provide current information on a patient. All patient
charts must include the listed personal/ biographical data. |
Patient Name or ID Number
on Each Page
(N) |
The patient who received the documented care must be easily
identified on each page. |
Medication Allergies
or NKA
(O,N) |
Allergies, or NKA if no allergies to medications exist, should be
clearly and easily identified on each patient's record. This aids in the
prescription of medications in a therapeutically safe and effective
manner. |
Problem List Completed
(N) |
Significant illnesses and medical conditions need to be clearly
identified in each patient's record. Maintaining problem lists enhances
patient information from which a provider can effectively develop a
treatment plan. |
HISTORY
|
Medical (E,O,N)
Family (E,O)
Social (E,O,N) |
All patients need to have documentation of medical, family and social
histories in their medical records to provide a database from which a
planned course of treatment and care can be developed. Past medical
history 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. For
all patients 14 years and over, notation concerning use of cigarettes (12
years and older), alcohol, substance abuse and sexually-transmitted
diseases is present. It is recommended that patient histories be
routinely updated with biennial physicals. If there is no change, a note
to this fact can be made on the original history form and dated. The
history form should be initialed and dated when it is reviewed or
updated. |
Interval History
(E) |
An interval history is a brief or detailed summary of events since
the last Well Child visit. For a child without sick visits, documentation
such as "no problems" is adequate. For a child with sick visits,
documentation such as "4-year-old with resolving otitis" is
acceptable. |
Ancillary Reports
(O) |
Ancillary reports (such as physical therapy, outpatient treatment,
speech, dietitian, employer, school, home care, emergency room, etc.)
provide information to enhance continued development of treatment
plans. |
Inpatient Discharge
Summaries Filed
Chronologically
(O)
|
Knowledge of inpatient treatment provided enhances the continued
development of treatment plans. |
Consultative Report for
Each Referral
(O,N)
Communication Form from
BH Provider Referral
(N)
|
Each referral to another provider requires documentation of the
evaluation and/or treatment performed to enhance continued development of
treatment plans. Physicians must date and sign or initial to indicate
their review.
For members receiving Behavioral Health services, the communication form
or documentation regarding the referral for services should be in the
record.
|
Physical Exam Offered/
Completed
(E,O,N) |
Through complete physical examinations, providers can encourage
health maintenance and/or preventive health measures. Refer to Priority
Health's
Preventive Health Care Guidelines for appropriate exam frequency and
prevention screening. If a member is seen for an illness or injury and
has not had a physical exam, a recommendation that the patient return for
an exam should be made and documented in the record. |
Documentation of Counseling
for Identified Risk Factors
(N) |
As health risk factors are identified for each patient, appropriate
discussions or counseling of the potential effects of those risks is
recommended. |
Smoking History Assessed
(H)
Smoking Cessation
Counseling
(H)
|
As health risk factors are identified for each patient, appropriate
discussions or counseling of the potential effects of those risks is
recommended. Smoking history should be assessed at every visit. If the
patient is a smoker, smoking cessation should be addressed at every visit
(along with vital signs) and documented. |
DOCUMENTED EACH VISIT
|
Blood Pressure as
Medically
Necessary
(E,PH) |
Blood pressure measurement is an essential indicator of
cardiovascular health. Patients seen for episodic care only should have
their blood pressure checked periodically.
Children must have blood pressures taken at every physical, beginning at
age 3. Either the blood pressure or an indication that it was attempted
must be documented.
|
Chief Complaint/Reason
for Visit
(O,N) |
To provide a database from which a planned course of treatment and
care can be developed. |
Physical Exam Findings
(N) |
Physical exam findings must be documented in the record. |
Diagnosis/Medical
Impression
(N) |
A diagnosis/medical impression consistent with the physical exam
findings must be documented in the record. |
Studies Ordered (Lab,
X-ray, EKG)
(N) |
To provide a database from which a planned course of treatment and
care can be developed. There is no evidence that the patient is placed at
inappropriate risk by a diagnostic or therapeutic procedure. |
Therapies Administered
& Prescribed
(N) |
To provide a database from which a planned course of treatment and
care can be developed. Treatment plans are consistent with
diagnosis. |
Recommendations/
Instructions/
Interpretive Conference
(E,N) |
An interpretive conference is performed at each Well Child visit
explaining the pertinent findings of the examination. Health education is
designed to heighten a recipient's awareness and knowledge regarding the
prevention of accidental injury or poisoning, and disease or disability
caused or aggravated by personal health practices. Documentation may
reflect whether or not the parent/guardian asks questions and appropriate
information is given by the practitioner. |
Evidence of Follow-Up
(N) |
Encounter forms or notes have a notation regarding follow-up care,
calls, or visits. The specific time of needed follow-up care is noted in
weeks, months, or as needed. |
Anticipatory Guidance
(E) |
Anticipatory guidance includes upcoming milestones and expectations
based on age. Documentation of discussions, counseling, and education
regarding age appropriate concerns regarding growth and development,
problem prevention, and safety issues. Medicaid only. |
|
All Entries are Legible
(N)
|
All entries in the patient record must be legible to someone other
than the writer. |
All Entries are Dated
& Signed
(O,N) |
Physicians and staff need to date and sign, or initial, all entries
in patient records. Dated and signed entries serve to:
(1) Prevent potential confusion over
entered data should questions arise regarding authenticity of the
documentation in the medical record
(2) Validate the source of information in
cases where transfer of records becomes necessary.
If initials are used instead of signatures, a signature register needs to
be kept on file. If an electronic charting system is in use, the
electronic signature must be password-protected. |
LAB & RADIOLOGY REPORTS
|
Initialed by Physician (N)
Date of Review
Documentation
(N)
|
All lab, x-ray and consult reports need to be dated and signed, or
initialed, by the physician to show they have been reviewed in a timely
manner. If initials are used instead of signatures, a signature register
needs to be kept on file. |
Abnormal Results
Noted Regarding
Lab & X-rays
(N) |
It is essential that providers take appropriate action to address
abnormal laboratory and/or radiologic findings. |
ADULT RECORDS
|
| Tetanus (O,N) |
All adult records should include documentation of tetanus
immunization status. If the status is unknown and not easily obtained
from a previous physician, the Centers for Disease Control recommends
that the tetanus booster be given. Tetanus boosters should be updated
every ten years and assessed by the third visit or with the physical
exam. |
PEDIATRIC RECORDS
|
Immunizations
(E,O,N) |
All pediatric records should include a completed immunization record.
Immunizations should be assessed at every opportunity.
|
Head Circumference
(E)
|
An indicator of normal growth and development. Must be
documented from birth to 24 months of age. Medicaid only. |
Height and Weight
(E) |
An indicator of normal growth and development. Medicaid
only. |
PEDIATRIC SENSORY SCREENING
|
Hearing
(E) |
Hearing needs to be assessed to determine the need for appropriate
intervention if abnormalities are noted. Any age-appropriate subjective
or objective hearing test is acceptable. Medicaid only.
- Startling or clapping is acceptable with young children.
- For children 6 months to 2 years, any indication that the child is
hearing normally is acceptable, such as "follows two-word commands",
"points to a named picture", "points to body part", "understands
commands", etc.
|
Vision
(E) |
Vision needs to be assessed to determine the need for appropriate
intervention if abnormalities are noted. Any age-appropriate subjective
or objective vision test is acceptable. Medicaid only.
- Documentation such as "follows with eyes" or "tracks" is
appropriate for young children.
- For children 6 months to 2 years, any indication that the child is
seeing normal is acceptable, such as "points to named picture", "points
to body part", "scribbles", "kicks ball", etc.
|
Developmental Assessment
(E)
|
Developmental assessment is an indicator of normal development. A
developmental assessment may include a listing of milestones achieved, a
list of tasks the child is able to perform and/or an assessment of gross
and fine motor skills. Developmental assessment could include
intellectual, psychosocial, and cognitive development measures as well as
speech and language assessments. Medicaid only.
|
PEDIATRIC ASSESSMENT AND PROCEDURES
|
Dental Inspection
(E)
|
A description of dentition or condition of primary or permanent teeth
constitutes a dental inspection. Gum description for babies is
acceptable.
A complete dental inspection should be performed and documented. A
referral to a dentist for further treatment, should be made as needed.
Medicaid only. |
Nutritional
Assessment
(E)
|
Adequate nutrition is important for normal growth and
development. Nutritional assessment may include dietary intake, eating
habits, and/or discussion of food choices. Medicaid only.
|
Blood Lead
(E)
- Risk Assessed
- Lab Performed
|
Lead poisoning is considered the most important
environmental health problem for young children. The prevention of lead
poisoning is accomplished through the removal of environmental lead and
lead screening. Leas exposure may occur in any demographic grup, but the
two variables highly associated with lead exposure are 1) living in a
home built before 1950 and 2) low income level.
This must be documented for all Medicaid members between 12 and 24
months of age.
|
Hemoglobin/
Hematocrit
(E)
|
Hemoglobin and hematocrit screening is an indicator of
many disease states. Medicaid only.
|
Sickle Cell
(E)
|
If the child was born in a Michigan
hospital on or after October 1, 1987, the sickle cell test is not
required. For children with all or some black heritage, the test is
required prior to the child's 21st birthday unless electrophoresis for
sickle cell was done when the child was at least six months of age, the
results are known to the parent, and are documented in the patient's
history. Medicaid only.
|
Tuberculin Test
(E)
- Risk Assessed
- Lab Performed
|
Risk assessments focus on whether the
childe has been exposed to a relative, playmate, or other acquaintance
with inactive or active TB. Medicaid only.
|
Urine Test
(E)
|
Urine screening is an indicator of many disease states.
A urine screen is to be performed at 5 years of age and for any sexually
active male or female. Medicaid only.
|
Injury Prevention (E)
|
Education needs to be performed at each Well Child
visit.
|
Sleep Position Counseling
(E)
|
Educate parents/guardians to position infants on their
backs to sleep through 6 months of age to decrease the probability of
SIDS (Sudden Infant Death Syndrome).
|
Violence
Prevention
(E)
|
Education needs to be performed at each Well Child
visit. |
