IF IT'S NOT WRITTEN, IT'S NOT DONE

Well-documented medical records accurately and completely reflect the care provided to a patient and facilitate the retrieval, continuity and sharing of clinical information. Medical records that are poorly maintained, incomplete and/or illegible can impede the level of communication between healthcare providers; negatively impact member care and treatment planning; and leave openings for legal problems should a question of negligence arise in the future. Each year, HNE conducts medical record documentation audits. During these audits, random sample of medical records are analyzed for clinical quality and coordination of care. Based on this year's medical record audit results, HNE has selected the following area for performance improvement activity: documentation of follow-up and coordination of care between PCPs and specialists (especially behavioral health practitioners).

The importance of the PCP's role as coordinator of care and custodian of his or her patient's complete medical profile cannot be overstated. The responsibility of managing relationships between treating physicians is equally important as that of diagnosis, treatment and referral. Without it, the contemporary viewpoint of treating the whole person may be lost. The PCPs have the role of team coordinator and, as such, have the rare opportunity to establish expectations pertaining to the exchange of clinical information between themselves and the specialist. Additionally, the PCP relays the standard that all physicians treating a member share relevant information regarding the member's diagnosis and treatment to assure true coordination of care.

As collaborators in care, HNE solicits provider suggestions and comments helpful to improving medical record documentation in general and/or specific processes or policies providers may have found particularly helpful in assuring the quality of medical record documentation or overcoming barriers to patient follow-up.

Please fax such suggestions or comments to Pat Scheer, Quality Operations Manager at 413-233-2607 or email at pscheer@hne.com