Ambulatory Pediatric/adult Medical Record Review Template
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1Ambulatory Pediatric/Adult Medical Record Review
Practitioner:
ID#:
Practice Site
Address:
Reviewed
By:
Date:
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Does the practice site use EMRs to manage patient’s healthcare?
Yes
No
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Allscripts
MEDENT
eClinicalWorks
Logician
NextGen
Other
Does it support direct feeds from other systems (lab/hospital/specialist)?
❏
❏
Are you participating in a regional health information organization (RHIO)?
Yes
No
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❏
Are you using an ePrescribing tool?
Yes
No Which One:
What percent of prescriptions are written electronically?
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❏
If no, does the practice site plan to implement eRx?
Yes
No When:
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Is the practice site using an asthma treatment plan or school action plan form?
Yes
No
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If no, is there an action plan written in the progress notes?
Yes
No
Does the practice site have policies and procedures that demonstrate that they do not discriminate
in the delivery of health care services and accept for treatment any member in need of health care
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services they provide?
Yes
No
1
2
3
4
5
6
7
8
9
10
Member ID #
Is the medical record legible?
*1. The medical record contains a problem
list or easily identified notation in the
progress notes of significant illness,
chronic conditions.
*2. Medication allergies/adverse reactions
are prominently noted or NKA is
clearly documented in the record.
*3. History and physical examination
noted for each visit.
*4. The record contains a medication list
or easily identified notation in the
progress note of all current
medications with dosages.
*5. There is documentation of clinical
findings and evaluation for each visit?
*6. Is there documentation that
preventive services/risk screening
was offered?
*NCQA states that each medical record must include these six core elements.
If the reviewer is unable to read the majority of the medical record, copies should be requested for Medical
Director Review. If the reviewer identifies a potential quality concern, copy five medical records for Medical
Director review.
Comments:
June 2016
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Parent category: Medical