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Medical Record Survey Results 2009
Survey Shows High Level of Member Care
The ODS goal is 80 percent for each standard. In 2009, overall scores met or exceeded the standard in the following areas:
- Security measures for the Electronic Medical Record (EMR) *Nurse Reviewers commented: “many more offices are moving to an EMR. Those offices say that the transition to the EMR is painful but they are very happy with the final EMR advantages.”
- Documentation of medical history and physical are current, medication lists, ancillary services and diagnostic tests ordered
- Continuity and coordination of care between primary and specialty medical practitioners
- Provider follow-up efforts to determine whether there were cognitive or language barriers when the patient was not compliant with practitioner instructions
Areas for Improvement
The four areas below represent improvement opportunities in medical record documentation. Each of these resulted in a global aggregate score lower than 80 percent.
| Statements | Aggregate Score |
|---|---|
| If the patient has a Medicare plan there is documentation prominently displayed as to whether or not the patient has executed an advance directive or Physician Orders for Life- Sustaining Treatment (POLST). | 5.4% |
| If there is current history of tobacco use there is documentation of tobacco cessation advise found in the past year | 35% |
| There is documented use of a standardized depression and/or alcohol screening instrument. (eg. PHQ-9 or CAGE) | 0% |
| Coordination of care with behavioral health specialist is documented | 25% |
For More Information
Thank you to everyone who participated in the 2009 medical record review. Your partnership with ODS shows continuing commitment to promote safe and effective care to our members.
Download a copy of an advance directive, CAGE, PHQ-9 or PHQ-9 scoring instructions). If you have any questions, please contact the
As part of our continuing commitment to ensure safe and effective care to our members, ODS nurse reviewers survey the charts of a random selection of primary care practitioners, obstetrics and gynecology specialists, women’s healthcare specialist, and behavioral health practitioners to determine whether established record-keeping standards are being met.
About The Survey
The survey consists of 37 questions developed to meet the standards of the National Committee for Quality Assurance, Centers for Medicare and Medicaid Services, and clinical practice standards recommended by the CDC.
This year questions regarding behavioral health were added to monitor documentation of coordination of care between the physical and mental health of the patient.
In addition questions regarding access to care were added.
