POLICY/PROCEDURE: MEDICAL RECORDS REQUIREMENTS AND AUDITS
DEPARTMENT:
HEALTH SERVICES - Quality Improvement Department
Original Effective Date: 12/96
Last Updated or Revised: 6/06
POLICY PURPOSE
To establish the criteria against which practitioners’ medical record-keeping practices are evaluated and
the evaluation process
POLICY STATEMENT
 Medical record-keeping standards shall be established for the patient medical records maintained by
– adult and pediatric primary care physicians (PCPs) and specialty care practitioners (SCPs)
– high-volume behavioral health practitioners1
 PCPs, SCPs and high-volume behavioral health practitioners’ medical records will be reviewed
periodically to assess compliance with medical records standards currently in effect.
RESPONSIBILITY
The Quality Improvement (QI) Department is responsible for

developing medical record-keeping standards in concert with the medical group or IPA medical
directors and QI Committees

ensuring that those standards are consistent with the expectations of contracting health plans for
appropriate recordkeeping

ensuring that the standards are regularly updated to reflect current health plan requirements

designating and training the medical group or IPA staff who will conduct medical records audits
to assess compliance with established standards

communicating current recordkeeping standards and audit results to practitioners or their office
managers, the QI Committee and contracting health plans
SCOPE
A review of the medical record ensures that documentation of patient information is organized logically
and reflects all aspects of patient care including ancillary services, demonstrating performance, quality
in terms of legibility, completeness, confidentiality ,continuity of care and including patients’ primary
spoken language . The medical recordkeeping criteria include NCQA standards relating to the following:




1
organization/availability
privacy and consent documents
patient demographic data (including patients’
primary spoken language)
legibility





encounter documentation
objective findings
follow-up plan
preventive services
patient education
High-volume is determined annually based on data for patient encounters in the preceding 12-month period. The five BH
specialists with the greatest volume of encounters in that period are deemed high volume practitioners.
Page 1 of 6
POLICY/PROCEDURE: MEDICAL RECORDS REQUIREMENTS AND AUDITS
DEPARTMENT:
HEALTH SERVICES - Quality Improvement Department
Original Effective Date: 12/96
Last Updated or Revised: 6/06



current/updated lists of identified problems
and medications
medical history, past and present
diagnosis



chart completion
continuity of care
notification of test results
A.
Medical record audits are conducted in conjunction with the onsite facility reviews as part of the
initial pre-contracting Credentialing process (see QI Policy Practice Site Requirements and
Audit Process) and periodically thereafter.
B.
For initial credentialing, the scope of the initial audit is confined to a limited range of criteria and
is performed in conjunction with the pre-contractual practice site audit (see QI Policy Practice
Site Requirements and Audits).
C.

If the practitioner is new to practice, new to the area and not assuming an existing
practice, or assuming the practice of a non- medical group or IPA panel practitioner, the
medical record audit is performed as a mock audit in order to preserve confidentiality of
patient information that the medical group or IPA is not authorized to view prior to a
contract being executed with the practitioner.

If the practitioner is assuming the practice of a medical group or IPA panel practitioner
whose services are terminating for any reason, the medical group or IPA is contractually
entitled to review actual patient records.
Post-contractual random medical record audits are conducted as time permits in order to increase
the number of medical records exposed to occasional review, as follows:

when the QI Department becomes aware through other performance monitoring
activities, such as complaints/grievances, quality of care issue and appeals management,
that a practitioner’s medical recordkeeping practices may not be satisfactory

as an extemporaneous process as determined by the QI Department

when a recordkeeping issue that may indicate a widespread systemic problem is
frequently identified in the course of scheduled medical record audits

when a contracting health plan requires periodic assessment of the medical group or IPA
practitioner records for its enrolled members
PROCEDURE
1.
The Audit Process
1.1 The Credentialing Department notifies the QI Department of practitioners being initially
credentialed or in a re-credentialing cycle who require medical record audits.
1.1.1
For PCPs, OB/GYNs and BH practitioners being initially credentialed, a mock audit
will be performed solely on a sample record combined with interviews of the staff
responsible for medical records. Actual patient records may not be reviewed prior to
Page 2 of 6
POLICY/PROCEDURE: MEDICAL RECORDS REQUIREMENTS AND AUDITS
DEPARTMENT:
HEALTH SERVICES - Quality Improvement Department
Original Effective Date: 12/96
Last Updated or Revised: 6/06
execution of a contract with the practitioner unless the practitioner has obtained the
patient’s written consent for audit of his/her record.
1.1.2
For PCPs, OB/GYNs and BH practitioners being re-credentialed, a medical record
audit will be conducted only if the practitioner reaches the threshold for complaints or
quality of care/service issues requiring review by either the QI Committee or the
medical director (see QI Policy Complaints and Grievances). Complete the audit
prior to the date the practitioner’s credentials are scheduled for review by the
Credentialing Committee. Results are provided for consideration by the Credentialing
Committee and the QI Committee or medical director, as applicable, at that time.
1.1.3
For focused audits directed by the QI Department, conduct the audit within the time
frame and to the extent (i.e., specific indicators vs. complete audit) set by the QI
Department.
1.2 The QI Clinical Analyst identifies the patients whose records will be subject to the audit:
Pre-contractual audits of PCPs, OB/GYNs and BH Specialists: Ask the provider to
supply a mock medical record constructed to reflect the office’s standard medical records
content and structure. Alternatively, the practitioner may obtain the written consent of up to
five patients permitting review of actual records.
PCPs and OB/GYNs Being Re-credentialed: Randomly selects five medical records for
any practitioner who has reached or exceeded the threshold for complaints and quality of
care/service issues. The files may be selected in advance or upon arriving at the practice site
and audited at the time of the re-credentialing facility audit.
BH Providers Being Re-credentialed: Due to confidentiality issues, a mock medical
record review can be supplied, or a patient’s medical record can be reviewed if there is
consent form signed by the patient or the patient’s legal representative. If the latter, select up
to five such records for review.
Focused Audits: Identify the individual practitioners within the specialty(ies) subject to the
focused audit and randomly select up to five patients for each practitioner. The record
selection may be made in advance of the audit or upon arriving at the practice site.
1.3 The QI Clinical Analyst notifies the designated auditor to contact the practitioner
practitioner.
1.4 The designated auditor schedules the date and forwards to the practitioner a copy of the
applicable Medical Record Audit Tool most recently approved by the QI Committee.
1.4.1
If the medical record audit is for pre-contractual purposes, forward the Practice Site
Audit Tool that contains the applicable medical record criteria for a mock audit (see
Attachment 1: PCP and OB/GYN Practice Site Audit Tool or Attachment 1:
Behavioral Health Specialist Practice Site Audit Tool).
Page 3 of 6
POLICY/PROCEDURE: MEDICAL RECORDS REQUIREMENTS AND AUDITS
DEPARTMENT:
HEALTH SERVICES - Quality Improvement Department
Original Effective Date: 12/96
Last Updated or Revised: 6/06
1.4.2
If conducting a post-contractual random medical record audit, forward a copy of the
applicable Medical Record Audit Tool (see Attachment 3: PCP and Physician
Specialist Medical Record Audit Tool and Attachment 4: Behavioral Health
Practitioner Medical Record Audit Tool).
1.4 Medical records audits must be practitioner-specific. If more than one practitioner’s records
are audited at the same site, prepare a separate audit tool that reports the results of all records
audited.
2.
Performance Scoring, Compliance Thresholds and Corrective Actions
2.1 Upon completion of the audit, tally the results and annotate the audit tool accordingly.
2.1.1
Medical records must have an overall compliance rate of 80% on all indicators
combined, plus compliance on each of the critical elements, as follows:

For new panel applicants (i.e., pre-contractual audits): 100%

For all other audits, including health plan-specific audits: 80% or the performance
goal established by the QI Department or QI Committee, as applicable for the
audit project.
2.2 The QI Clinical Analyst requests a corrective action plan (CAP) when a practitioner’s
medical records do not meet the compliance threshold applicable for that practitioner.
2.2.1
Notify the contact person at the practitioner’s office in writing of the results,
specifying the items requiring a CAP and any follow-up audit that will be conducted,
including the time frames for each.
2.2.1.1
Include a copy of each practitioner’s scored audit tool.
2.3 CAPs must be received in the QI Department within no more than 30 days of the date the
results are forwarded to the practitioner’s office.
2.3.1
If a CAP is not received within 30 calendar days, the QI Clinical Analyst calls the
contact person at the practitioner’s office as a reminder and extends the deadline by
five calendar days.
2.3.1.1
If the CAP still is not received by the extended due date, the QI Clinical
Analyst notifies the Medical Director for further direction.
2.3.1.2
The QI Clinical Analyst reports practitioners who fail to respond to
corrective action requirement the QI Committee.
2.3.2. Upon receipt of a CAP, the QI Clinical Analyst follows-up to verify that the
corrective action has been implemented.
2.3.2.1 If the CAP pertains to a critical element, schedule a follow-up audit in six months.
Page 4 of 6
POLICY/PROCEDURE: MEDICAL RECORDS REQUIREMENTS AND AUDITS
DEPARTMENT:
HEALTH SERVICES - Quality Improvement Department
Original Effective Date: 12/96
Last Updated or Revised: 6/06
2.3.2.2
If the CAP does not pertain to a critical element, the practitioner’s written
attestation of having corrected the problem will suffice.
2.4 The QI Clinical Analyst monitors past and current medical audit results to identify
substandard recordkeeping practices.
2.4.1
Compare the current audit results with those of previous medical records audits to
identify instances of non-compliance with the same elements or patterns of noncompliance that may indicate underlying practice issues.
2.4.1.1
3.
Discuss such instances with the QI Manager and the Medical Director to
determine whether a more stringent corrective or contractual action should
be considered.
Periodic Reporting of Medical Record Audit Results
3.1 For non-BH practitioners only, complete a Health Plan Medical Record Critical Elements
Audit Report of aggregate audit activity for each health plan requiring audits of their
members’ medical records (see Attachment 5).
3.1.1 Present results data and corrective action issues to the QI Committee in the quarter in
which the audits were completed. A copy may be supplied to contracting health plans
upon request.
3.2 Complete a Practice Site and Medical Record Audit Activity Report of aggregate audit
activity, and present results data and corrective action issues to the QI Committee and
contracting health plans quarterly (see Attachment 6).
4.
Retention of Medical Record Audit Results
4.1 Forward a copy of the completed audit tools, including CAPs and correspondence to the
Credentialing Department immediately upon concluding the audit and CAP process.
4.2 Retain the originals of the completed audit tools in the QI Department.
Page 5 of 6
POLICY/PROCEDURE: MEDICAL RECORDS REQUIREMENTS AND AUDITS
DEPARTMENT:
HEALTH SERVICES - Quality Improvement Department
Original Effective Date: 12/96
Last Updated or Revised: 6/06
RELATED POLICIES
QI Policy Practice Site Requirements and Audit Process
QI Policy Complaints and Grievances
ATTACHMENTS:
Attachment No.
Title
1
Practice Site Audit Tool (PCPs and OB/GYNs)
2
Practice Site Audit Tool (Behavioral Health Specialists)
3
Medical Records Audit Tool (PCPs and Physician Specialists)
4
Medical Records Audit Tool (Behavioral Health Specialists)
5
Health Plan Medical Record Critical Elements Audit Report
6
Practice Site and Medical Record Audit Activity Report
Page 6 of 6