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Criteria (indicators) to be evaluated must include, but are not limited to, the following:
1. Demographic/personal data are noted in the record, complete patient name, date of birth, home
address and phone number, sex, marital status, insurance, and Member identification number
2. An emergency contact person’s name, address, and phone number, or that there is no contact person
is noted in the medical record
3. Each page of the medical record contains patient’s name or Bravo Health identification number
4. All entries are legible, signed and dated
5. Significant illness, medical and psychological conditions are indicated on the medical list
6. Prescribed medications, including dosage, date of initial and/or refill prescriptions are listed
7. Allergies and adverse reactions to medications are prominently noted in the record
8. Appropriate past medical history in the medical record
9. History and physical are included in the record
10. The working diagnosis are consistent with the findings
11. Treatment plans are consistent with the diagnosis and is noted on every visit note
12. There is documentation that the Member participated in the formulation of the treatment plan
13. All diagnostic and therapeutic services for which a Member was referred for are in the medical
record and there is evidence that the practitioner reviewed these reports
14. There is explicit notation in the medical record of follow-up plans related to consultation, abnormal
laboratory, and imagining study results
15. Chronic or unresolved problems from previous visits are addressed in subsequent visits
16. There is no evidence that the patient is placed at risk by a diagnostic or therapeutic procedure
17. There is evidence of patient/significant other teaching
18. There is evidence that medical care is offered in accordance to Bravo Health clinical care guidelines
19. The medical record contains appropriate notation concerning use of alcohol, cigarettes and
substance abuse
20. There is notation regarding follow-up care, calls or visits
21. The specific time of return is noted in days, weeks, months, or as needed
22. There is a separate medical record for each patient
23. The documentation is consistent with ICD-9 codes
24. Only authorized staff have access to medical records
25. Medical records are easily located and retrieved
26. Forms used for documentation are consistent in all records
27. There is a completed immunization record in accordance with the organization’s adult preventive
guidelines
28. Chart is orderly
29. Preventive screenings/services are recommended
30. There is documentation of a discussion of a living will or advance directives for patients 65 years of
age or older/or patients with life threatening conditions
31. Clinical findings/evaluations are documented
Provider must meet these requirements for medical record keeping. If opportunities for quality
improvement are identified, Bravo Health will present these opportunities and implement interventions.
