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Standards for medical record documentation

December 2, 2013

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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 check-ups, it is important to have a record for patients who are seen only for acute care visits or whom you see at multiple visits for management of chronic conditions.

Some practices use a separate form designed specifically for yearly well-visits 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 necessary medical record documentation:

  • Remember to review preventive health and cancer screenings with each patient on an annual basis.
  • Review Clinical Alerts* provided by IBC via the NaviNet® web portal prior to scheduled visits to identify and address gaps in care.
  • Remind female patients covered under an HMO plan 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*, please review the Clinical Alerts Overview, which is located in the Administrative Tools & Resources section of IBC NaviNet Plan Central.

Standards for maintaining appropriate medical records can be found in the Provider Manual for Participating Professional Providers (Provider Manual), which is available on IBC 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.

*The Clinical Alert feature is currently disabled, but access will be re-established in mid-December.

NaviNet? is a registered trademark of NaviNet, Inc., an independent company.

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