2014 NCQA PCMH Documentation Checklist

PCMH 3C Factor 1-10 ☐Must Pass ☐Critical Factor ☐Corporate Survey

To understand the health risks and information needs of patients/families, the practice collects and regularly updates a comprehensive health assessment^ that includes:

  1. ☐Age- and gender appropriate immunizations and screenings
  2. ☐Family/social/cultural characteristics
  3. ☐Communication needs
  4. ☐Medical history of patient and family
  5. ☐Advance care planning (NA for pediatric practices)
  6. ☐Behaviors affecting health
  7. ☐Mental health/substance use history of patient and family
  8. ☐Developmental screening using a standardized tool (NA for practices with no pediatric patients*
  9. ☐Depression screening for adults and adolescents using a standardized tool*
  10. ☐Assessment of health literacy

^The practice should consider how its comprehensive health assessment helps establish criteria and supports a systematic process for identifying patients for care management in PCMH 4A

Documentation Required

☐Report(s) or Record Review Workbook*

☐Records or Files*

Screen Shots, i.e., electronic “copy” may be used as 1) examples (system capabilities of an electronic health record—EHR) 2 materials (Web site resources) 3 reports (logs, patient lists) or 4) records (e.g. documentation of clinical advice in the medical record

Report

Aggregated data showing evidence ☐Stage 2 Core Meaningful Use Requirement*

Does the Report include the following?

☐Practice Name

☐De-identified PHI

☐Reporting period current, within the past 12 months

☐Correct time frame (at least 3 months)

☐Report is not future dated

☐Displays numerator, denominator, and percent

☐Text boxes, arrows, or other methods identify important headers/sections

☐Text boxes, arrows, or other methods briefly explain the importance to the elements

☐Data was entered in the medical record for more than 50 percent

PCMH 3C Factor 1-10

Records or Files

Patient files or registry entries documenting action taken; data from medical records

* If using the Record Review Workbook examples are required demonstrating how each factor is documented.

*Factor 8 AND 9 require a completed form, even if the Record Review Workbook is not being used

Do the Records or Files include the following?

☐Practice Name

☐De-identified PHI

☐Current, within the past 12 months

☐Text boxes, arrows, or other methods identify important sections

☐Text boxes, arrows, or other methods briefly explain the importance to the elements

☐Factor 8 completed form

☐Factor 9 completed form

Does this documentation meet the intent of the factor?

☐Yes ☐No

If no, suggestions to meet the intent

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