4/02/2002; 03/17/2004; 10/08/2006
Standard Operating Procedures
Front Desk Medical Record Review
Center for Eye Care
1. patient demographics
2. 3 required signatures with verification
a. patient
b. attending optometrist
c. student
3. ICD-9 codes
4. CPT codes
5. insurance information
6. next appointment time
7. financial information
a. charges
b. adjustments
c. payments
II. Review Compulink Practice Management database for completeness and accuracy of financial transactions
1. charges
2. adjustments
3. payments
4. attending optometrists performing service
5. financially responsible party
III. On the Compulink financial screen indicate
1. insurance authorization numbers
2. attending optometrist for Medicare
V. Enter in Compulink Practice Management database
1. correct insurance policy number
2. date of release (original date of service)
3. clear inactive insurance carriers
VI. Make necessary corrections
1. notify attending optometrists and students of the need for corrections before checkout
2. notify Center Manager of continued need for repeated corrections
Appropriate health education is documented on all patients
Care is rendered in a timely and appropriate manner
All pages contain patient identification
There is biographical/personal data
There is only one patient's medical record in a chart
All progress notes are signed or initiated by writer
Every entry is dated
The record is legible to someone other than the writer
Errors are appropriately marked through and Initialed (i.e. no white out or black out used)
All pages are secured
Allergies and adverse reactions or the notation NKA is clearly documented
Past medical history is documented
Past history relating to condition is documented
Physical findings are recorded at every encounter
Diagnosis is recorded at every encounter
Presenting problem or symptoms are documented
Documentation of smoking, if relevant to condition
Documentation of alcohol use. if relevant to condition
Documentation of illicit drug use. if relevant to condition
Instructions regarding dose, frequency and length to take are documented when medication is prescribed
Medication given In the office is identified by name, site route given & dose
The plan of treatment is documented
Follow up plan is documented
Problems from previous visits are addressed
There is evidence of continuity and coordination of care between specialist and primary care physician
If diagnostic tests are ordered, the results are documented
The physician has noted the results of the diagnostic tests
The physician has documented what was done regarding abnormal results
The patient received notification of abnormal test results
Signed informed consents are in chart when procedure requires IV sedation or other forms of anesthesia except local anesthesia
The office has a confidentiality policy
If the physician has more than one office there is a procedure to ensure the medical record is available whenever the member is seen