The National Committee for Quality Assurance (NCQA) offers 21 record documentation elements. Of these, six are crucial to developing high-quality documentation:
- Each patient’s ongoing illnesses and/or medical conditions are clearly indicated.
- Medication allergies and adverse reactions are prominently noted. In the case of no known allergies or no history of adverse reactions, this is also noted.
- Past medical history (for patients seen three or more times) is easily identified, including serious accidents, surgeries, and illnesses. For children and adolescents (18 years and younger), this includes prenatal care, birth complications, surgeries, and childhood illnesses.
- Working diagnoses are consistent with documented findings.
- Treatment plans are consistent with documented diagnoses.
- Documentation indicating diagnostic or therapeutic procedures is not contraindicated.
In addition to NCQA guidelines, if you use Electronic Health Records, make sure these elements are included for appropriate documentation:
- Personal biographical data (patient address, employer, home and work telephone numbers, and marital status).
- For patients 12 years and older, the use of cigarettes, alcohol, and illegal substances is noted (if patient is seen three or more times, query substance abuse history).
Setting a minimum standard of documentation for your practice and implementing these elements into your patient clinical record, signals your desire for quality, purposeful documentation and your commitment to delivering high quality care.