Medical Record Survey results 2010
As part of our continuing commitment to ensure safe and effective care to our members, each year 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 49 questions developed to meet the standards of the National Committee for Quality Assurance, Centers for Medicare and Medicaid Services, Oregon Division for Medical Assistance Programs and ODS policy and procedure.
Several questions were included to help us 1) monitor compliance with our access standards; 2) assess adoption of health information technology; and 3) assess practice systems for behavioral health screenings. These questions were not included in the scoring.
Survey shows high level of member care
ODS strives to obtain an 80 percent score for each standard. In 2010, overall scores met or exceeded the standard in the following areas:
- The use of security measures for the Electronic Medical Record (EMR)
- Privacy and security of records and provisions for non-English speaking and/or impaired members
- Continuity and coordination of care between primary and specialty medical practitioners
- Documented screening for tobacco use at every medical encounter for patients aged 10 and older
Making progress
Aggregate scores for behavioral health screening showed significant improvement since our 2009 review. The favorable results are an encouraging sign that providers are increasingly adopting best practices. We continue to work collaboratively with medical providers to encourage these best practices. Download a copy of the CAGE, AUDIT, PHQ-9 or PHQ-9 scoring form.
Areas for Improvement
The five 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 |
|---|---|
| For Medicare members, prominent display of documentation indicating whether or not the patient has executed an advance directive or Physician Orders for Life-Sustaining Treatment (POLST). | 22.4% |
| If there is an immunization record, it is kept current. | 70.8% |
| In adults aged 19 and older, there is an appropriate medical history, including serious illnesses, surgeries, family history and mental health history. (For records of patients aged 18 and younger, the global score was 68%.) | 55.5% |
| Documented vision screening to detect Amblyopia and Strabismus in children prior to school admission, given once, preferably sometime between age three and five. | 66.3% |
| A colorectal cancer screening for adult females aged 50 and older. (For records of the same screening for adult males aged 50 and older, the global score was 67.8%.) | 71.3% |
For More Information
Thank you to everyone who participated in the 2010 medical record review. Your partnership with ODS shows continuing commitment to promote safe and effective care to our members, helping them get well sooner and live well longer.
If you have any questions about this survey, please call our credentialing office at 503-265-5682, or toll-free at 800-852-5195.
Download a copy of an advance directive or call 503-265-5682.
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