Medical Evaluation Of Treatment printable pdf download

Medical Evaluation Of Treatment

Physician Name:

Office Manager:

Office Address:

Specialty:

Date:

Reviewer Name:

Patient Name:

Chart/Member ID:

Point

Yes

Value

Score

Is the chart accessible?

Do all pages contain patient ID (name/ID #)?

Is there personal/biographical data?

Is the provider identified on each entry?

Are all entries dated?

Is the record legible?

Are significant illnesses and medical conditions indicated on

the problem list?*

Are allergies and adverse reactions to medications prominently

displayed or, if the patient has no known allergies or history of

adverse reaction, is this appropriately noted in the record?*

Is there an appropriate past medical history in the record (for

patients seen three or more times), which includes serious accidents,

operations or illnesses, emergency care, and discharge summaries?

Age 18 and under should include prenatal care, birth, operations and

childhood illnesses.*

Is there documentation of smoking habits and history of alcohol or

substance abuse (age 12 and older)?

Is there a pertinent history and physical exam?

Are labs and other studies ordered, as appropriate, and reflect

PCP review?

Are working diagnoses consistent with findings?*

Do plans of action/treatments appear consistent with diagnosis(es)?*

Is there a date for a return visit or other follow-up plan for each encounter?

Are problems from previous visits addressed?

Is there evidence of appropriate use of consultants?

Is there evidence of continuity and coordination of care between

primary and specialty physicians?

Do consultant summaries, lab and imaging study results reflect

PCP review?

Pract Clinkal Medical Record Audit

Medical Evaluation Of Treatment