Provider # Full Scope DHCS Site # Medical Record Review Survey 202 Attachment B California Department of Health Care Services Medi-Cal Managed Care Division Health Plan: Central California Alliance for Health Review Date Last review Provider/Address Phone Fax Contact person/title Other Providers Reviewer/title Visit Purpose Site-Specific Certification(s) Provider type Clinic type Initial Full Scope Monitoring AAAHC JCAHO Family Practice Internal Medicine Primary Care Community Periodic Full Scope Follow-up Focused Review Ed/TA Other (type) CHDP NCQA CPSP ne Other Pediatrics OB/GYN General Practice Specialist n-physician Mid-level Practitioner (type) Hospital FQHC Rural Health Other (type) Solo Group Staff/Teaching Scoring Procedure Medical Record s Compliance Rate te: Ten (0) medical records may be surveyed in any combination, but must not exceed 00 points total for preventive care sections. Pts Poss Pts. I. Format (0) 80 II. Documentation (0) 70 III. Cont./Coord. (0) 80 IV. Ped. Preventive (5) 95 V. Adult Preventive (5) 75 VI. OB/CPSP Prev. (5) 50 Totals: NA % Scoring is based on 0 medical records. ) Add criterion points given for each individual section. 2) Adjust score for criteria (if needed). Subtract points from total points possible. 3) Add points given for all sections. 4) Divide total given by 400 or by the adjusted total points. 5) Multiply by 00 to determine compliance (percent) rate. 6) Calculate. Points Given / Total Adj. Pts. = Decimal X 00 = Compliance Rate # MDs #Adult Charts # Peds Charts # OB Charts te: Any section score of < 80% requires a CAP for the entire R, regardless of the Total R score. Exempted Pass: 90% /above Conditional Pass: 80-89% t Pass: Below 80% CAP Required DUE Other follow-up CAP closed Next Review Due: Provider: DHCS Site # Provider ID#
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I. Format Criteria te: A Format section score < 80% requires a CAP for the entire R, regardless of the Total R score. 0 A. An individual medical record is established for each member. B. Member identification is on each page. C. Individual personal biographical information is documented. D. Emergency contact is identified. E. Medical records on site are consistently organized. F. Chart contents are securely fastened. G. Member s assigned primary care physician (PCP) is identified. H. Primary language and linguistic service needs of non-or limited-english proficient (LEP) or hearing-impaired persons are prominently noted. 8 Provider: 3 DHCS Site # Provider ID#
II. Documentation Criteria te: A Documentation section score < 80% requires a CAP for the entire R, regardless of the Total R score. 0 A. Allergies are prominently noted. B. Chronic problems and/or significant conditions are listed. C. Current continuous medications are listed. D. Signed Informed Consents are present when any invasive procedure is performed. E. Advance Health Care Directive information is offered. (Adults 8 years of age or older; Emancipated minors) F. All entries are signed, dated and legible. G. Errors are corrected according to legal medical documentation standards. 7 Provider: 4 DHCS Site # Provider ID#
III. Coordination/Continuity of Care Criteria te: A Coordination/Continuity section score < 80% requires a CAP for the entire R, regardless of the Total R score. 0 A. History of present illness is documented. B. Working diagnoses are consistent with findings. C. Treatment plans are consistent with diagnoses. D. Instruction for follow-up care is documented. E. Unresolved/continuing problems are addressed in subsequent visit(s). F. There is evidence of practitioner review of consult/referral reports and diagnostic test results. G. There is evidence of follow-up of specialty referrals made, and results/reports of diagnostic tests, when appropriate H. Missed primary care appointments and outreach efforts/follow-up contacts are documented. 8 Provider: 5 DHCS Site # Provider ID#
IV. Pediatric Preventive Criteria (continued on next page) te: A Pediatric Preventive section score < 80% requires a CAP for the entire R, regardless of the Total R score. te: 0 A. Initial Health Assessment (IHA) Includes H&P and IHEBA. History and physical (H&P) 2. Individual Health Education Behavioral Assessment (IHEBA) B. Subsequent Periodic IHEBA C. Well-child visit. Well-child exam completed at age appropriate frequency 2. Anthropometric measurements 3. BMI percentile 4. Developmental screening 5. Anticipatory guidance 6. STI screening on all sexually active adolescents, including chlamydia for females 7. Pap smear on sexually active females D. Vision Screening Pediatric Preventive continued on next page Provider: 6 DHCS Site # Provider ID#
IV. Pediatric Preventive Criteria (continued from previous page) te: A Pediatric Preventive section score < 80% requires a CAP for the entire R, regardless of the Total R score. 0 E. Hearing Screening F. Nutrition Assessment G. Dental Assessment H. Blood Lead Screening Test I. Tuberculosis Screening J. Childhood Immunizations. Given according to ACIP guidelines 2. Vaccine administration documentation 3. Vaccine Information Statement (VIS) documentation 9 Provider: 7 DHCS Site # Provider ID#
V. Adult Preventive Criteria (continued on next page) te: An Adult Preventive section score < 80% requires a CAP for the entire R, regardless of the Total R score. 0 A. Initial Health Assessment (IHA): Includes H&P and IHEBA. History and physical (H&P) 2. Individual Health Education Behavioral Assessment (IHEBA) B. Subsequent Periodic IHEBA C. Periodic Health Evaluation according to most recent USPSTF Guidelines D. High Blood Pressure Screening E. Obesity Screening F. Lipid Disorders Screening Adult Preventive continued on next page Provider: 8 DHCS Site # Provider ID#
V. Adult Preventive Criteria (continued from previous page) te: An Adult Preventive section score < 80% requires a CAP for the entire R, regardless of the Total R score. 0 G. Tuberculosis Screening H. Breast Cancer Screening I. Cervical Cancer Screening J. Chlamydia Infection Screening K. Colorectal Cancer Screening L. Adult Immunizations. Given according to ACIP guidelines 2. Vaccine administration documentation 3. Vaccine Information Statement (VIS) documentation 5 Provider: 9 DHCS Site # Provider ID#
VI. OB/CPSP Preventive Criteria (continued on next page) te: An OB/CPSP Preventive section score < 80% requires a CAP for the entire R, regardless of the Total R score. Age 0 A. Initial Comprehensive Prenatal Assessment (ICA). ICA completed within 4 weeks of entry to prenatal care 2. Obstetrical and Medical History 3. Physical Exam 4. Lab tests 5. Nutrition 6. Psychosocial 7. Health Education 8. Screening for Hepatitis B Virus 9. Screening for Chlamydia Infection B. Second Trimester Comprehensive Re-assessment C. Third Trimester Comprehensive Re-assessment. Screening for Strep B D. Prenatal care visit periodicity according to most recent ACOG standards OB/CPSP continued on next page Provider: 0 DHCS Site # Provider ID#
VI. OB/CPSP Preventive Criteria (continued from previous page) te: An OB/CPSP Preventive section score < 80% requires a CAP for the entire R, regardless of the Total R score. 0 Age E. Individualized Care Plan (ICP) F. Referral to WIC and assessment of Infant Feeding status G. HIV-related services offered H. AFP/Genetic screening offered I. Domestic Violence/Abuse Screening J. Family Planning Evaluation K. Postpartum Comprehensive Assessment 20 Provider: DHCS Site # Provider ID#