Three Different Types of External Review

Medical records must meet expectations for three different
types of external review: quality assurance, legal,
and auditing. A good record will provide enough
information to satisfy inquiries made by any of these
bodies. The following specific examples of information
to be included in records of particular types of
encounters may assist physicians in understanding
what is required to ensure that their records are sufficient
for all purposes.

The Periodic or Annual Health Examination
Primary health care providers conduct periodic (or
annual) health examinations for health maintenance
and disease screening. The difference between these
examinations and the more frequent physician/patient
encounter is that these examinations are more comprehensive.
This must be reflected in the medical
record.
This type of encounter should be recorded as a periodic
health exam. It is advisable to use the CPP to
review and update the patient’s medical history, family
and social history, ongoing health concerns or problem
list, immunizations, allergies, and medications.
(The purpose of taking the family and social history is
to generate a risk profile for diseases based on age, gender, family history, and occupation.
The risk profile
serves to direct further history-taking, the physical
examination and screening tests, as well as necessary
patient education and health promotion). The record
should show evidence that appropriate screening and
preventive care is taking place as the patient progresses
through his or her life.
The physical examination should include all body
parts and systems appropriate to the age and gender
of the patient.
The treatment plan, if any, including tests or procedures
ordered and any advice given, should also be
documented.
Discussion of treatment options, explanation of significant
complications and potentially serious adverse
effects of medications should also be included in the
chart, along with referrals to other health care professionals,
where applicable.