Medical Record Review
Periodically, Meridian conducts a medical record review to ensure contracted practitioners maintain medical records in a current, detailed, and organized manner. Taking provider and service type utilization into account, a review of sample records from multiple health systems and provider offices was completed in October. Each record was carefully reviewed and scored using the criteria below:
| No. | Criteria Description |
|---|---|
| 1 | Provider has documented results of X-rays, and/or examinations performed. |
| 2 | Provider has documented Inpatient, ambulatory, ancillary, and/or emergency care performed. |
| 3 | Provider has documented all other providers participating in member's care. |
| 4 | Provider has documented review of services furnished by other providers. (consultation reports) |
| 5 | Provider has documented member's significant illness. |
| 6 | Provider has documented member's history of current medical conditions noted, including date. |
| 7 | Provider has documented presenting complaints and initial diagnostic impression of member. |
| 8 | Provider has documented member's psychological conditions. |
| 9 | Provider has documented member's examination findings |
| 10 | Provider has documented current treatment plan. |
| 11 | Provider has documented a current and prn medication list and is updated as necessary, indicating dose and date of start, stop, and/or renewed. |
| 12 | Provider has documented member's allergies and adverse reactions (or a notation that the member has no know allergies (NKA or NKDA) or no known history of adverse reactions). |
| 13 | Provider has documented Evidence thet an Advance Directive been offered to member. |
| 14 | Provider has documented past medical history |
| 15 | Provider has documented risk factors and applicable preventive services for the member relevant to the member's particular treatment. |
| 16 | Provider has documented Signed and dated by the medical professional rendering the services. (handwritten signature, unique electronic identifier or initials) |
While we saw needs for improvement in documentation of evidence of a member’s Advance Directive (criteria no. 13), our audit reflected vast improvements in medical records for the member’s allergies (12), and for recording other providers involved in the member’s care (3), both in detail and comprehensive documentation. For any health systems/providers scoring below 80% in the listed criteria, a letter will be sent to note areas where improvement in medical record documentation is needed.