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Standards for medical record documentation

December 1, 2014

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Documentation of preventive health screenings is an essential part of comprehensive quality care. In addition to keeping medical records for patients' regular checkups, it is important to have a record for those patients that are seen only when they come in for acute care visits, and for those patients that you see at multiple visits for management of chronic conditions.

Some practices use a separate form designed specifically for a patient's well-visit to capture physical evaluation and preventive care assessments. This allows for accurate tracking of preventive care screenings and routine health assessment documentation.

The following tips can help you maintain the necessary medical record documentation:

  • Remember to review preventive health and cancer screenings with each patient on an annual basis.
  • Prior to scheduled visits, review Clinical Alerts provided by AmeriHealth via the NaviNet® web portal to identify and address gaps in care.
  • Remind female patients with HMO insurance about Direct Access OB/GYNSM and mammography screenings.
For practices that use electronic medical records (EMR), finding a program that contains specific screens to capture preventive health care measures may be helpful in providing consistent, quality care to your patients.

For more information on Clinical Alerts, review the Viewing Clinical Alerts and Clinical Care Reports guide, located in the NaviNet Transaction Changes section of our System and Process Changes site.

Standards for maintaining appropriate medical records can be found in the Provider Manual for Participating Professional Providers (Provider Manual), available in the Current Publications section of AmeriHealth NaviNet Plan Central. A paper copy of the Provider Manual can be ordered by submitting an online request or by calling the Provider Supply Line at 1-800-858-4728.

NaviNet® is a registered trademark of NaviNet, Inc.

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