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Medical Record Documentation Requirements

November 21, 2019

To: All Providers

Accurate, complete, and legible medical record documentation is essential for delivering high-quality patient care.

To improve adherence and consistency of medical record documentation, we perform an annual medical record review audit based on New York State Department of Health (NYSDOH) and the Centers for Medicare & Medicaid Services (CMS) standards.  Adult primary care and pediatric records are evaluated and scored against elements of 26 set measures.

               Adult Care
  • Culturally competent care
  • Patient personal/biographical data to include address, gender, home phone or current contact number, employer work contact information, marital status, and an emergency contact as applicable
  • Sexual activity
  • Substance use
  • A signed Healthcare Proxy/Advanced Directive in the record, or documentation that a discussion took place
  • Body mass index (BMI)
  • Adult immunization history
Pediatric   Care          Ages 2-18 years               
  • BMI/BMI Percentile
  • Nutrition
  • Physical activity
Ages 12-18 years
  • Culturally competent care
  • Nutrition
  • Physical activity
  • Risk behaviors/sexual activity
  • Depression
  • Tobacco
  • Substance use/alcohol

A score from 1-5 is given (5 is the highest score attainable.) Physicians need at least an overall score of 4 out of 5. All physicians passed the 2019 medical record review audit with an average of 4.73. 


How to improve medical record documentation

  • BMI percentile for children and adolescents must include a height and weight measurement during the same year.
  • For adults (age 18 and over), a health care proxy/advance directive should be signed or discussed with documentation present in a prominent part of the patient’s medical record.
  • Documentation of adult immunization history detail must include the date the immunization was administered. A statement of “up-to-date” does not meet the standard.
  • Culturally competent care can be addressed by documenting at least one of the following: race, ethnicity or culture of the patient; language the patient speaks; use of an interpreter, or discussion of any cultural issues considered for patient care. 

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