Medical Record Survey results 2010

As part of our continuing commitment to ensure safe and effective care to our members, each year Moda Health nurse reviewers survey the charts of a random selection of primary care practitioners, obstetrics and gynecology specialists, women’s healthcare specialist, and behavioral health practitioners to determine whether established record-keeping standards are being met.

About The Survey

The survey consists of 49 questions developed to meet the standards of the National Committee for Quality Assurance, Centers for Medicare and Medicaid Services, Oregon Division for Medical Assistance Programs and Moda Health policy and procedure.

Several questions were included to help us 1) monitor compliance with our access standards; 2) assess adoption of health information technology; and 3) assess practice systems for behavioral health screenings. These questions were not included in the scoring.

Survey shows high level of member care

Moda Health strives to obtain an 80 percent score for each standard. In 2010, overall scores met or exceeded the standard in the following areas:

Making progress

Aggregate scores for behavioral health screening showed significant improvement since our 2009 review. The favorable results are an encouraging sign that providers are increasingly adopting best practices. We continue to work collaboratively with medical providers to encourage these best practices. Download a copy of the CAGE, AUDIT, PHQ-9 or PHQ-9 scoring form.

Areas for Improvement

The five areas below represent improvement opportunities in medical record documentation. Each of these resulted in a global aggregate score lower than 80 percent.

Improvement opportunities
Statements Aggregate score
For Medicare members, prominent display of documentation indicating whether or not the patient has executed an advance directive or Physician Orders for Life-Sustaining Treatment (POLST). 22.4%
If there is an immunization record, it is kept current. 70.8%
IIn adults aged 19 and older, there is an appropriate medical history, including serious illnesses, surgeries, family history and mental health history. (For records of patients aged 18 and younger, the global score was 68%.) 55.5%
Documented vision screening to detect Amblyopia and Strabismus in children prior to school admission, given once, preferably sometime between age three and five. 66.3%
A colorectal cancer screening for adult females aged 50 and older. (For records of the same screening for adult males aged 50 and older, the global score was 67.8%.) 71.3%

For More Information

Thank you to everyone who participated in the 2010 medical record review. Your partnership with Moda Health shows continuing commitment to promote safe and effective care to our members, helping them get well sooner and live well longer.

If you have any questions about this survey, please call our credentialing office at 503-265-5682, or toll-free at 800-852-5195.

Download a copy of an advance directive or call 503-265-5682.

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