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1. Completed problem list is documented.
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INDICATORS:
a) There is a completed problem list in a prominent location in the record.
b) Recurrent or chronic illnesses or diseases are indicated on the problem list.
DrKnow automatically creates a synopsis of recurrent, chronic and acute problems. The problems are correlated with any procedures performed, and medications prescribed. Furthermore, the synopsis dates each problem, displays the number of instances and occurrences of the problem, and shows whether the problem is active or resolved. |
2. Allergies are prominently displayed. |
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INDICATORS:
a) The chart is clearly marked with member's allergies.
Allergies are displayed in an allergy list, and the physician is warned in the medical record if the patient has allergies. |
3. Medical history is appropriately recorded. |
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INDICATORS:
a) The member's medical history is documented including family history and previous illnesses/surgeries.
b) If medical history is completed by member, there is notation of review by practitioner.
The patient's medical history is displayed in the synopsis, which includes diagnoses, procedures and medications, as mentioned in #1 above. This window makes a distinction between medical history as documented by the practice, and medical history reported to the practice from outside sources (e.g. a medication prescribed by an outside physician).
Family history is summarized in the family history synopsis. |
4. Pertinent history and physical exam is documented. |
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INDICATORS:
a) For each encounter, there is documentation regarding the history of the current illness, when applicable, and the ensuing physical exam.
For each encounter there is a separate visit note which allows documentation for vital signs, the history of present illness, review of systems, physical exam and general comments. |
5. Follow-up plan and/or return visit is documented for each encounter. |
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INDICATORS:
a) Patient instructions, including when to return or referral to another practitioner, are given with each encounter, when appropriate.
The physician's follow-up plan is documented in the Diagnoses & Treatments window, and further documentation can be recorded in the general comments section. The Referral List tracks patient referrals. |
6. Continuity/coordination of care between primary care practitioner and any independent practitioner or provider is documented. |
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INDICATORS:
a) There is documentation from any independent practitioner or provider regarding findings an plans of treatment, (Examples: MD, Hospital, Home Health Agency, Skilled Nursing Facility), OR
b) There are notes of calls from any individual practitioner within the medical record.
All outside documentation and communication can be incorporated into the medical record by scanning and attaching information, by entering outside findings into the synopsis as ancillary history, and by documenting communication / coordination of care in the Extra Office Contacts section of the medical record. |
7. Consultant, laboratory and imaging studies reflect practitioner review. |
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INDICATORS:
a) Written correspondence and test results are initialed by the practitioner or noted in text of medical record.
Written correspondence is saved and automatically appended to the patient's medical record. Test results also reside in the medical record. Furthermore, test results and other correspondence can be emailed to the patient, and such correspondence will automatically be documented in the patient's record. |
8. Immunization record is complete (for pediatric members only -- below age 16). |
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INDICATORS:
a) All immunizations according to the Preventive Care Timeline are complete and noted within the medical record.
Upon opening a record, the physician is reminded of which immunizations are due for the patient. When the physician selects the desired immunization, it is documented in the immunization summary sheet. The physician can also search the patient population to determine which patients are due for specific immunizations. |
9. Preventive services are appropriately used. |
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INDICATORS:
a) There is documentation that the member received or was instructed to receive at least one preventive health screen or examination within the past year.
Upon opening a record, the physician is reminded of which preventative care items are due for the patient. To document that care was given, the physician need merely click the appropriate preventative care or anticipatory guidance items as they are performed. The physician can also search the patient population to determine which patients are due for specific preventative care or anticipatory guidance items. |
10. Health guidance/counseling is appropriately provided to members. |
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INDICATORS:
a) There is documentation that the member smokes or does not smoke.
b) If the member smokes, there is documentation that the member was advised to stop smoking.
Smoking counseling can be documented either by an ROS Screening Questionnaire (an optional module), in the comment section of visit notes or in the preventative care / anticipatory guidance summary sheet. |
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Scoring for the Medical Record Documentation Review is as follows:
TOTAL SCORE:
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9-10 points |
Exceeds criteria |
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8 points |
Meets criteria |
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7 points and below |
Does not meet criteria |
DrKnow scores a perfect 10 out of 10 for the medical record documentation review, and still has more to offer, e.g. disease management and national standards of care.
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