Medical Records

Medical Record Standards and Requirements

Presbyterian must ensure that all members' medical records are accurate and complete. Presbyterian reports information to several regulatory and accreditation agencies including the National Committee for Quality Assurance (NCQA), the State of New Mexico Human Services Department (HSD), the Centers for Medicare and Medicaid Services (CMS), and the New Mexico Department of Insurance (DOI). These agencies require that certain items be documented in every member's chart.

A recent audit of Pediatrician and Primary Care Practitioner member charts showed opportunities for improvement in the following areas:

  • Documentation of any history of smoking, alcohol use, and substance abuse (for any member over the age of 12)
  • Documentation of past medical history
  • Documentation of medication history including what has been effective, what has not, and why. This should include consistent documentation of refills, including long-term prescriptions such as asthma inhalers. The history should also include any follow-up on new prescriptions.

Advance Directive documentation is required for all charts of adult members ages 18 and older. This would include documentation that durable Power of Attorney and Advanced Directive information was provided to the member, and was signed and dated by both the member and the practitioner. This documentation should also include if the member executed Advanced Directives.

If you have any questions about documentation standards, contact Jené Breitburg-Moya, RHIT, at 505-923-5729 or Additional information regarding chart documentation is available in the following documents: