Ambulatory Medical Record Review Tool
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4AMBULATORY MEDICAL RECORD REVIEW TOOL
Physicians Medical Group of San Jose, Inc.
1565 Mabury Road, Suite D
San Jose, CA 95133
DATE: ____________________________________
EVALUATOR: ______________________________
TELEPHONE: ______________________
PROVIDER: _____________________________________________________________________
ADDRESS: ______________________________________________________________________
PHONE ( PROVIDER): _______________________
PHYSICIAN CODE: __________________
SPECIALTY: FP GP IM ______________
Scoring
Chart 1
Chart 2
Chart 3
Chart 4
Chart 5
Y = Yes, Criteria Met
Date of Birth
N = No, Criteria Not
Met
Member ID#
Age/Sex
%
I.
Medical Records Documentation/Chart
Maintenance
+
A.
Do all pages contain patient’s name
or ID Number?
+
B.
Chart contents secured
C. Is there biographical/personal data?
(as follows):
1. Address
2. Employer
3. D.O.B.
4. Emergency Contact/Phone
5. Home Phone #
6. Work Phone #
7. Marital Status
D. Do all entries in the medical record
contain author identification?
E. Are all entries in the medical record
dated?
+
F.
Is the record legible to someone
other than the writer?
+
G. *
Significant illnesses and medical
conditions are indicated on the
Problem List.
1
EXCEL MSO, LLC Ambulatory Medical Record Review Tool
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Parent category: Medical