Medicare (CMS) Standards for Medical Records and Quality of Care
The organization formerly known as HCFA (HealthCare Financing Organization),
which is now known as the Centers for Medicare and Medicaid Services (CMS),
as well as an organization that oversees the quality of managed care plans
(National Committee for Quality Assurance - NCQA) have standards for medical
records that apply to the ambulatory and hospital environment. Many of these
standards are listed below:
- Each page has the patient's name or ID number.
- All entries in the record contain the author's signature, intials or
electronic identifier as well as the author's clearly printed name.
- All entries are dated (and in the hospital, timed).
- All entries are legible to individuals other than the writer.
- Medication list is completed, including dosages and date of inital or
refill prescription.
- Medication allergy or lack thereof and adverse reactions are prominently
noted.
- Problem list is completed, including significant illnesses and medical and
psychological conditions.
- A Subjective, Objective, Assessment, Plan (S.O.A.P.) format is used to
describe the problem list and this includes a treatment plan.
- There are notes regarding follow-up care, calls and visits, and specific
time of return.
- Unresolved problems from previous visits are addressed in subsequent visits.
- An immunization record is present.
- Preventive screening and services are offered according to current national
standards (e.g., mammograms, bone density, pap/pelvic, colonoscopy, eye
examinations, thyroid function, cholesterol, blood sugar, Flu shots...)
An example of preventive services based on age per one managed care plan are
listed at: https://www.aetna.com/providerehealthoffice/
- Information about Advance Directives is noted.
- Identification of all (other) providers participating in the member's care
and information on the serv ices provided by these providers is listed.
- Vital signs including weight, height, BP, pulse are noted. In the hospital,
temperature, respiratory rate, pain assessment.
- There is evidence that the physician has reviewed laboratory and other
studiesand that the member has been notified of results before filing record.
- Abnormal lab and other studies have an explicit note regarding follow-up
plans.
- Documentation of communication with specialists is noted.
- Phone communications with patients are documented.
- There is a system to document missed appointments.
- Medical records are protected from public access (see also HIPPA
regulations).
- Each patient has an individual medical record (e.g., not grouped by family).
IPRO (www.ipro.org) does surveys on behalf of Medicare (CMS) to assure that
Quality of Care Measures are followed (www.cms.gov); in 2003 these include:
-LDL cholesterol assessment after MI
-LDL >130 treated after MI by discharge
-Mammograms every two years starting age 50 through 69
-Diabetics have retinal exam at least every 1-2 years
-Diabetics have lipid profile every 1-2 years
-Diabetics have Hb A1c at least annually (we actually suggest more often)
-CHF patients discharged with advice on ALL of the following:
-activity level; diet; meds; f/u appt; weight monitoring; what to do if
worsening symptoms at home; smoking cessation advice; ACEI prescribed
if systolic dysfunction (EF < 40%)
-CHF patients have LVF assessed during or shortly after hospitalization (if
not done shortly before admission)
-Flu shots given during flu season, especially Oct-Feb in hospital after
pneumonia if seasonal shot not already given to those over 50 yo
-Pneumococcal vaccine given, including in hospital after pneumonia if not
given before to those over age 65 yo
-Pneumonia patients receive first dose of antibiotics within 4 hours after
arrival at the hospital and that blood cultures drawn first
-Pneumonia patients who are immunocompetent and that have community acquired
pneumonia (CAP) receive antibiotics that follow CAP guidelines
-Pneumonia patients have ABG or pulse oximetry within 24 hours of admission
-Pneumonia patients who smoke receive cessation advice/counselling prior to
discharge
