Letter to CMS - Medicaid Managed Care Policies - Agency for ...

Agency For Health Care Administration
Managed Care Organizations
Medical Record Audit Tool
Medical Record Review Tool
Item Number Contents of the Medical Record: Found in Record Reference Comments
5
6
7
8
Contains:
a. Entries that indicate a chief complaint or purpose of the visit
Managed Care Organizations Page 2
Medical Record Audit Tool F1_03_10
Florida Medicaid
Y N
Y N
b. Objective findings of the practitioner Y N
c. Diagnosis or medical impression Y N
Contains entries that indicate:
a. Studies ordered (lab, x-ray, etc.)
Y N N/A
b. Therapies administered and prescribed Y N N/A
Contains entries showing the name and profession of the provider
rendering services, including the signature or initials of the provider.
Contains entries showing:
a. Disposition
Y N
Y N N/A
b. Recommendations Y N N/A
c. Instructions to the member Y N N/A
d. Evidence of follow-up Y N N/A
e. Outcomes of services Y N N/A
9 Contains an immunization history Y N N/A
10
11
Contains information relating to the member’s use of tobacco products,
alcohol or substance abuse
Contains summaries of all emergency care and hospital discharge
summaries with appropriate medically indicated follow-up
Y N N/A
Y N N/A
42 CFR 456
CC-VII.J.1.e
42 CFR 456
CC-VII.J.1.e
42 CFR 456
CC-VII.J.1.e
42 CFR 456
CC-VII.J.1.f
42 CFR 456
CC-VII.J.1.g
42 CFR 456
CC-VII.J.1.h
42 CFR 456
CC-VII.J.1.i
42 CFR 456
CC-VII.J.1.i
42 CFR 456
CC-VII.J.1.i
42 CFR 456
CC-VII.J.1.i
42 CFR 456
CC-VII.J.1.i
42 CFR 456
CC-VII.J.1.j
42 CFR 456
CC-VII.J.1.k
42 CFR 456
CC-VII.J1.l