Ambulatory Medical Record Review Tool (Page 3 of 4) in pdf

Ambulatory Medical Record Review Tool Page 3

Scoring

Chart

Y = Yes, Criteria

Met 1 Point

N = No - 0 point

Member ID #

NA = Not Applicable

Age/Sex

1 point

b) history of alcohol use

COMMENTS

c) history of substance abuse

d) psycho/social/behavioral

e) serious accident

f) surgical procedures

g) illnesses

2. Children / Adolescents: Past

medical history/questionnaire for

pts. Seen > 3 times includes:

a) smoking habits (> 14 yrs. old)

b) history of alcohol use ( > 14

yrs. old)

c) history of substance abuse (14

yrs.)

d) * surgical procedures

e) * childhood illnesses

f). personal/psychosocial / family

history

pre-natal / delivery history (if

applicable)

B. Is there a completed immunization

record? ( Use current guidelines

for scoring)

C. Is there documentation of health

education?

Are preventative services used

according to accepted guidelines?

Critical elements to be met for acceptable standards

Safety measures

EXCEL MSO, LLC Ambulatory Medical Record Review Tool

Ambulatory Medical Record Review Tool Page 3