Top 10 List of SMRF "Improvement Areas"

Over the past year, the DC Partnership to Improve Children’s Healthcare Quality (DC PICHQ) has been working with pediatricians and family physicians to expand voluntary adoption and implementation of the HealthCheck standard medical record forms (SMRF) to improve the quality of well-child care and standardize well-child documentation throughout the District of Columbia.

Currently more than 80% of all District pediatric primary care practices have completed training and implemented the use of the HealthCheck SMRFs as a part of their practice more than 50,000 encounters entered into the HealthCheck Registry. Ultimately the registry will provide data to benchmark the city-wide delivery of services, gaps and target/measure for improvement interventions.

The DC PICHQ reviews 20% of all SMRFs submitted to Medicaid for submission to the HealthCheck Registry for quality and completeness and communicates data back to providers as part of practice based improvement efforts.

The following areas for improvement are common omissions/errors and apply to all participating practices:

• “Dental Referral” NOT Documented: The dental referral indicates that the provider has discussed the importance of good oral health, regular dental hygiene and referred the child to a dentist beginning at 2 years of age. In addition to the dental referral, HealthCheck also requires that the provider: perform one documented dental evaluation between 12 and 24 months of age, perform a dental evaluation and provide oral health education and anticipatory guidance at each preventive health visit, check for eruption of wisdom teeth, and evidence of tobacco use or eating disorders.
  
  
• Anticipatory Guidance NOT Documented: Health education, including anticipatory guidance, is required at each preventive health visit. Suggested health topics and age- appropriate guidance are available on the back side of each of the seven forms.
  
  
• Zip Lines Discouraged: DC Medicaid discourages the use of “zip lines” or vertical lines through one side of the check-box column indicating that the various components of the physical exam were each normal. The preferred format is to mark each box individually. To be considered complete, each component of the physical exam must be completed.
  
  
• Hole Punches Remove Data: Office staff should exercise caution when punching holes in the top or side of the forms not to punch through a data field. Frequently SMRFs are submitted with holes punched through one of three critical data elements: child’s name, DOB and/or date of visit. A missing or illegible entry in any of these fields voids the entire visit.
  
  
• Drug Allergy Blank: An entry in this field is required for all visits. “NKDA”or “Ø” are acceptable abbreviations to indicate that there are no known drug allergies.
  
  
• Vision Screen Missed: (required at 3,5,6,8,10,12,15,18 yrs old): must write in visual acuity and mark either corrected or uncorrected box or mark box next to unsuccessful attempt.
  
  
• Hearing Screen Missed: (required at 5,6,8,10,12,15,18 yrs old): must mark one of three boxes (passed, failed, or unsuccessful attempt).
  
  
• TB Risk Assessment Missed: (12 months to 21 years): Assess risk, if ‘high’ then check “PPD Ordered.” NOTE: All children entering school must have a PPD test prior to entrance.
  
  
• Cholesterol Risk Assessment Missed: (3 years to 21 years): Review risk factors. Must mark either “low” or “high." Note: AAP recommends lipid profile at ages 6, 8, 10 annually if at high risk.
  
  
• Unit of Measure NOT Indicated: Height and weight data must indicate the unit of measure expressed, US or Metric, by checking the appropriate box in the corresponding field.

For additional information on how to improve well-child documentation in your practice or to implement SMRFs in your practice contact Vincent Schuyler, DC PICHQ program director at 202- 884-3216 or via email at vschuyle@cnmc.org.