December 2016

2016 Medical Record Review

Blue Cross and Blue Shield of New Mexico’s (BCBSNM’s) Quality Improvement Department performs an annual medical record review to assess whether practitioners and practice groups meet the minimum New Mexico Administrative Code (NMAC) and Human Services Department (HSD) medical record documentation standards for our Blue Cross Community Centennial^SM members. Medical records are also evaluated according to BCBSNM standards.
BCBSNM randomly selected 20 primary care and obstetrics/gynecology provider groups having at least ten member encounters during the time period from August 2015 through September 2016. We requested a total of 200 medical records samples and received 180. We assessed and scored a minimum of five charts per provider group on NMAC and HSD standards. Minimum standards require an assessment of five charts to meet an overall threshold score of 80%.

Groups that do not meet the minimum threshold of 80% must provide a corrective action plan in writing within 30 calendar days to the Quality Improvement Department, which will be included in the next annual medical record review. Results are later presented to the Clinical Quality Improvement Committee (CQIC), which consists of medical directors, external practitioners, and members of BCBSNM’s management team.

Assessment results determined provider groups to be compliant on most standard requirements. Medical records contained proper documentation of current or existing problems, proper patient identification, and documentation for both encounter and entry dates. However, advance directive documentation was lacking on all medical records. Despite providers receiving a copy of the NMAC and HSD standards with the medical record request, upon review of medical records, BCBSNM found that an advance directive had not been discussed with the patient and was not included in the medical record. Discussing advance directives with members is mandated for Blue Cross Community Centennial providers.

To view, download, or print a sample of an advance directive form and to learn more about medical record review standards, please see the Blue Cross Community Centennial section of the Provider Reference Manual, which is located on our website. We would like to thank our primary care and obstetrics/gynecology health providers for their cooperation and diligence with their medical record documentation. Please contact BCBSNM’s Medicaid Quality Improvement Department at 1-855-699-0042 with questions or concerns.