Medical Evaluation Of Treatment (Page 2 of 2) in pdf

Medical Evaluation Of Treatment Page 2

Point

Yes

Value

Score

Does the care appear to be medically appropriate? (There is no

evidence that the patient was placed at inappropriate risk by

diagnostic or therapeutic procedure.)*

Is there a completed immunization record (age 13 and under)?

Are preventive services appropriately used?

Are advance directives present on the chart (age 21 and older)?

Does pediatric documentation include: (4 points total)

Growth chart (1.5 pts.)

1.5

Head circumference chart (1 pt.)

Developmental milestones (1.5 pts.)

1.5

Is there a list of current medications?

Are copies of any emergency treatment and/or hospital admission

present in the chart?

If a mental health problem is noted, was a referral made, or did the

PCP perform treatment?

If a substance abuse problem is noted, was a referral made, or was

treatment or education noted?

If smoking is noted, was patient advised to quit (age 12 and older)?

Is there evidence of blood lead risk assessment (verbal assessment or

blood lead test, ages 6 months to 6 years)?

TOTAL

100

*These critical elements must be met in addition to receiving an average score of 80 percent to achieve an acceptable

rating on the Clinical Medical Record Review.

PF-MULT-0019-12

Medical Evaluation Of Treatment Page 2