Providers with good clinical documentation processes know how vital this can be to delivering quality health care services. It not only helps their patients to receive the right care at the right time, but it also promotes a full, holistic viewpoint during all phases of treatment, and supports thorough communication across a variety of health care settings and provider types. This helps ensure continuity of care.

We conduct ambulatory medical record reviews annually

To support this important aspect of patient care, each year we randomly audit a sample of network-participating providers to validate they meet all medical record documentation requirements.

Ambulatory medical record review checklist

During an ambulatory medical record review, we may ask you to send a copy of your patient’s medical records. We will be reviewing for the following charting indicators:

• Updated problem list or summary of health maintenance exams.
• Current prescription medication list or medication notes.
• List of medications the patient is allergic to or does not tolerate.
• Adverse reactions to medications.
• Medical history (including initial health questionnaire form and updated form).
• Examinations that identify subjective and objective findings.
• Plan of treatment that is consistent with the diagnosis.
• Recommendation for follow up at each visit.
• Review of laboratory and diagnostic studies.
• Review of consult reports.
• Health screening for alcohol usage.
• Health screening for tobacco usage.
• Discussions about advance directive.

Information most frequently missing

Our most recent audits show the following information to be most frequently missing:

• Documentation of allergies and adverse reactions to medication.
• Screenings for alcohol and tobacco usage.
• Discussions about advance directive.

Please be sure to document a list of medication allergies with specific adverse reactions to each, information on health screenings completed for alcohol and tobacco, and any advanced directive information provided to or discussed with the patient.

View Cigna Healthcare documentation standards

Go to the Cigna for Health Care Professionals website (CignaforHCP.com) > Get questions answered: Resource > Medical Resources > Commitment to Quality > Quality > Medical Record Reviews.

Send questions to our dedicated email box

If you have questions about the ambulatory medical record review process, please send an email to our dedicated email box at DedicatedAMRRMailbox@Cigna.com. As a reminder, please include valid email addresses for both the provider and the office to help ensure we respond to the correct office staff.