17.4 OB/GYN Medical Record Review Tool
17.4 OB/GYN Medical Record Review Tool
17.4 OB/GYN Medical Record Review Tool
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CFHP<strong>OB</strong>/<strong>GYN</strong> SPECIALTY MEDICAL RECORD AUDIT TOOLPhysician: Nurse <strong>Review</strong>er: Date of <strong>Review</strong>:Provider Number:Provider Type:A. Documentation ______B. Continuity of Care ______C. Preventive Health _______________________________________________Plan -- Age--A. DOCUMENTATION1. Patient identification on each page2. Personal/Biographical information3. Allergies prominently noted4. Problem List (pts w/3 or more visits)5. Medication List (pts w/3 or more visits)6. Entries legible7. All entries contain author identification8. All entries are dated9. Advance Directives(Medicaid 18 & older – <strong>OB</strong>/PCPs)B. Continuity of Care10. Past medical history (pts w/3 or more visits)11. Tobacco, alcohol, & other substances useassessed (12 & older)12. Chief complaint noted13. History & exam pertinent to complaint14. Working diagnosis consistent with findings15. Basic teaching provided16. Appropriate plan of treatment17. Appropriate use of consults18. Appropriate studies ordered19. Unresolved problems addressed20. Physician review on studies21. Results of consultations are reviewed & filed22. Date of next visit/instructions for follow-up23. ER and Hospital reports/records24. Patient is not placed at inappropriate risk25. Evaluation of Abuse/neglect or othersocio environmental factors (Medicaid)VALIDATIONS - √ for compliance (not scored)26. Diagnosis Validation27. Claims Validation1 2 3 4 5 6 7 8 9 10 Y N Y+NSCOREYY+Nx100=% compliance<strong>17.4</strong> <strong>OB</strong>/<strong>GYN</strong> <strong>Medical</strong> <strong>Record</strong> <strong>Review</strong> <strong>Tool</strong>P: Quality Management\<strong>Medical</strong> <strong>Record</strong> <strong>Review</strong>\SFY2012\Audit <strong>Tool</strong>s Revised 12/04, 7/07, 1/10, 8/11H EALTH PLANSwww.cfhp.com149
CFHP<strong>OB</strong>/<strong>GYN</strong> SPECIALTY MEDICAL RECORD AUDIT TOOLPhysician: Nurse <strong>Review</strong>er: Date of <strong>Review</strong>:Provider Number:Provider Type:A. Documentation ______B. Continuity of Care ______C. Preventive Health ______1 2 3 4 5 6 7 8 9 10 Y N Y+NSCOREYY+Nx100=% compliance_________________________________________Plan -- Age--A. DOCUMENTATION1. Patient identification on each page2. Personal/Biographical information3. Allergies prominently noted4. Problem List (pts w/3 or more visits)5. Medication List (pts w/3 or more visits)6. Entries legible7. All entries contain author identification8. All entries are dated9. Advance Directives(Medicaid 18 & older – <strong>OB</strong>/PCPs)B. Continuity of Care10. Past medical history (pts w/3 or more visits)11. Tobacco, alcohol, & other substances useassessed (12 & older)12. Chief complaint noted13. History & exam pertinent to complaint14. Working diagnosis consistent with findings15. Basic teaching provided16. Appropriate plan of treatment17. Appropriate use of consults18. Appropriate studies ordered19. Unresolved problems addressed20. Physician review on studies21. Results of consultations are reviewed & filed22. Date of next visit/instructions for follow-up23. ER and Hospital reports/records24. Patient is not placed at inappropriate risk25. Evaluation of Abuse/neglect or othersocio environmental factors (Medicaid)VALIDATIONS - √ for compliance (not scored)26. Diagnosis Validation27. Claims ValidationP: Quality Management\<strong>Medical</strong> <strong>Record</strong> <strong>Review</strong>\SFY2012\Audit <strong>Tool</strong>s Revised 12/04, 7/07, 1/10, 8/11150 H EALTH PLANSwww.cfhp.com
CFHP<strong>OB</strong>/<strong>GYN</strong> SPECIALTY MEDICAL RECORD AUDIT TOOLPhysician: Nurse <strong>Review</strong>er: Date of <strong>Review</strong>:Provider Number:Provider Type:PREVENTIVE CARE_________________________________________Plan-- Age1 2 3 4 5 6 7 8 9 10 Y N Y+NSCOREYY+Nx100=% compliancePRENATAL CARE1. Comprehensive history documented2. Complete physical exam documentedINITIAL LAB WORK3. Hematocrit or hemoglobin4. Urinalysis5. ABO/Rh typing & antibody screening6. Rubella screening7. VDRL, Gonorrhea* & Chlamydia* Screening(* = Optional)8. Cervical Cytology (as needed)9. Hepatitis B Surface Antigen10. HIV screeningFOLLOW-UP <strong>OB</strong> VISITS11. Vital signs & weight12. Urine check for protein and glucose13. Fundal height measurement14. Edema check15. Signs & symptoms of preterm labor; or otherrisk factors16. Fetal heart tones noted17. Fetal movement notedFOLLOW-UP LABS18. Triple screen (8-20) weeks)19. Glucose challenge/H&H/Ab screen(24-28 weeks)20. Group B Strep/ H&H/ VDRL (35-37 weeks)POST PARTUM CARE21. Interim history & physical exam22. Evaluation of weight23. Vital signs24. Cervical Cytology (as needed)25. Family planning/contraceptive practices26. Education provided on STD prevention27. Assessment for postpartum depression<strong>GYN</strong> Preventive Care28. Pelvic & Pap Smear29. Mammogram (Every 1-2yrs for women 50 & older)30. Rubella Antibody Titer (High risk)31. Family planning/Contraceptive Practices32. Education provided on STD preventionX = Patient qualifies for screening but timeframe has not yet expiresP: Quality Management\<strong>Medical</strong> <strong>Record</strong> <strong>Review</strong>\SFY2012\Audit <strong>Tool</strong>s Revised 12/04, 7/07, 1/10, 8/11H EALTH PLANSwww.cfhp.com151
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