Documentation of Care Review

The objective of performing periodic documentation of care reviews is to evaluate the quality and appropriateness of PCPs’ office medical records documentation and to promote continuous improvements. Documentation is an important element in evaluating care and safety and promotes the delivery of continuity of care.

Documentation of care (DOC) reviews evaluate medical records and do not define standards of care or replace a physician’s judgment. They are performed on random samples of medical records annually. After a DOC review, Health Options will conduct a detailed follow-up with providers who have results less than 100 percent of documentation standards. Physicians will be notified in writing of deficiencies identified during the review, if applicable. Health Options will also provide guidelines and educational tools so physicians can improve medical records documentation.

Health Options requires that its physicians maintain a medical records system that is consistent with professional standards, protects the confidentiality of member records, and includes, but is not limited to, the following information and/or standards:

Record is legible.

Each page of office progress notes contains the member name and member identification number.
Provider is identified on each entry with signature or initials.
Record contains a current medication list or medications are listed in progress notes.
Reason for each office visit is clearly stated.
All entries are dated. Problems from previous visits addressed.
Objective findings are documented, including appropriate vital signs.
Diagnosis appears consistent with subjective and objective findings documented.
Treatment plans are consistent with diagnoses.
Lab and/or diagnostic studies are appropriate and reflect primary care review.
Consultation(s) present in the record reflect primary care review.
Follow-up plans are appropriate.
Biographical data includes date of birth, name, member identification number and sex.
Record contains a current problem list or problems are listed in progress notes.
Allergies/adverse reactions to medications are noted on the record.
Advance Directive is documented (at 18 years and greater) Pediatric and adolescent immunization records are complete and up to date.
Medical history is available. Inquiry/counseling regarding tobacco use is documented.
Inquiry/counseling regarding alcohol/substances is documented.
Complete baseline physical exam is documented.
Electronic Medical Record (EMR) for BCBSF internal use only and is not part of the physician’s scoring.

Preventive services/screenings services are offered, ordered or completed for adults and children in accordance with Health Options’ practice guidelines. Health Options has adopted guidelines from the USPSTF’s Guide to Clinical Preventive Services. Visit the Agency for Healthcare Research and Quality website for the latest age/gender specific clinical recommendations.

Records are stored securely. Only authorized personnel have access. Staff receives periodic training on member information confidentiality.