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Review Date: Provider: Location : Reviewer: Patient Name: Contracted Provider Medical Record Audit Tool Last Review Date: Clinic Name: Contact Person Name: Contact Person Phone: Medical Record Format: Patient DOB: Question Point value Yes / No / NA Comments Does chart contain past medical history, physical examinations, necessary treatments, and possible risk factors for the member relevant to the particular treatment? 0 Is there evidence that HIPAA privacy requirements are met and that privacy information is provided to patients and documented in the chart? 0 If the clinic has electronic medical records, do they have screen savers with password protection to prevent confidential information from being viewed by unauthorized people? 0 Are documents in the medical record securely attached in the chart? 0 Is there identification of all providers participating in the member's care and information on services furnished by these providers? 0 Do all chart notes generated by the provider under medical record review include the date of service, a legible signature, the provider's credentials, and authentication by the provider (for any documents generated by but not transcribed by the provider under review)? 0 Is there documentation of preventive care? 0 Page 2 of 4
Review Date: Provider: Location : Reviewer: Patient Name: Contracted Provider Medical Record Audit Tool Last Review Date: Clinic Name: Contact Person Name: Contact Person Phone: Medical Record Format: Patient DOB: Question Point value Is there documentation of education of self-care? 0 Yes / No / NA Comments Page 3 of 4
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