Treatment Record Review Results

UMBH reviews the treatment records of its high volume practitioners every year against its documentation standards. The documentation standards were adopted from twenty-four documentation guidelines proposed by the National Committee for Quality Assurance. UMBH's performance goal is 85 percent for each criterion.

Overall, results of the 2007 treatment record review found that UMBH’s practitioners were 94 percent compliant with our treatment record guidelines. Performance did not meet expectations in all areas, however. Areas of concern relate to documenting: allergies or the absence of allergies; dates of follow-up appointments or, as appropriate, a discharge plan; and continuity and coordination of care with the patient’s primary care clinician, consultants, ancillary providers, and health care institutions.

Practitioners whose treatment records were reviewed received their individual results and comparative data for all records reviewed.

Please encourage patients to sign a consent to release information to their primary care physicians and document your communication with PCPs. Communication with the patient’s PCP is important not only for continuity and coordination of care but also for patient safety.

Please click to view the documentation standards. We suggest that you print and post them in any location that will help you to meet our standards.

As a reminder, be sure to obtain informed consent for treatment and medication. ALWAYS MAKE SURE YOU HAVE A VALID INFORMED CONSENT ON FILE!

We thank the practitioners whose offices were included in this review and appreciate your cooperation with the treatment record review process.