Coordination of care is a significant factor in today?s health care
environment. With the increasing use of hospitals, urgent care centers, and
retail health clinics, as well as multiple specialty services, it can be
difficult to ensure that patients receive the best individual care. While
electronic record systems may improve coordination of care, communication
between specialists and primary care providers can still be challenging.
Independence has established medical records standards to facilitate
communication, coordination, and continuity of care and to promote efficient
and effective treatment. One of these standards refers to coordination between
providers of primary care and consultants.
Primary care
Primary care offices are generally the central point for care. Points to
remember include:
- For HMO members, ask about referrals the patient requested or that your
office provided. Referrals are part of the electronic record or patient chart
and can be checked when the patient signs in at the front desk. If the patient
was seen and no consultation is present, the staff can contact the office while
the patient is still in the office.
- For radiology studies or testing ordered by a consulting practice that need
to be coordinated by your office, check for a consultation note or call the
requesting office for information. Document the request in the patient record,
including the ordering consultant. Ask for a report to be sent to your office
as part of the consultation note.
- Document all recommendations or referrals for consultation and rationale in
the patient record. If a patient requested a referral, document the patient
request.
- Don?t forget about behavioral health. Discuss behavioral health concerns
with your patients or patient representatives and request permission to discuss
care with the behavioral health provider. Some behavioral health concerns or
treatments may affect or influence the patient?s response to medical care.
Document all discussions in the medical records.
- Make sure to review all consultation notes and initial or sign the
documents to indicate your review. Independence Medical Record Keeping
Standards require the ordering practitioner to initial the review.
Note: Review and signature by other professional staff in the office
do not meet this requirement.
Specialty care
Specialists may coordinate care and/or act as a primary care provider.
Points to remember include:
- For HMO members, send consultation notes/updates to the primary care
provider after each patient encounter.
- Document all recommendations or referrals for consultation and rationale in
the patient record. If a patient requested a referral, document the patient
request.
- Don?t forget about behavioral health. Discuss behavioral health concerns
with your patients or patient representatives and request permission to discuss
care with the behavioral health provider. Some behavioral health concerns or
treatments may affect or influence the patient?s response to medical care.
Document all discussions in the medical records.
- Make sure to review all notes received by the primary care provider or
other consultants. Initial or sign the documents to indicate your review.
Note: Review and signature by other professional staff in the office
do not meet this requirement.
Collaboration of care and medical record keeping standards are two
requirements for accreditation by the National Committee for Quality Assurance
(NCQA). NCQA views these standards as significant in providing quality and
comprehensive care to patients.
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 Independence
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.
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independent company.