(Private Sector) External Quality Review of Medicaid MCOs and Supporting Regulations in 42 CFR 438.360, 438.362, and 438.364

EQR PROTOCOL 4 – Validation of Encounter Data Submitted by the MCO
Attachment B: Medical Record Review Worksheet
The data tables in this Attachment are designed to assist the EQRO in conducting Protocol 4 for
validation of encounter data submitted by the MCO.

Table 1: Event Validation
Instructions: Complete this tool for each record in the sample. Record results from the Event
Validation (p. 1) and the Data Field Validation (p. 2) onto the Medical Record Results Summary
Sheet (Attachment II).

Reviewer Information
Reviewer:

Completion Date:

Identify Medical Record
Provider Name:
Patient ID Number:
Patient Name:
Patient Sex: M /F

Attending Physician Name:
Medical Record Number:
Patient DOB:

Dates of Service:
Begin Date:

End Date:

Event Validation
Is event present in
encounter data?

Is event present in medical record?

Match

(from medical record)

No
Match

a.
If no match is found (i.e., the event is missing either from medical record or from encounter data),
record results on Medical Record Results Summary Sheet (Attachment II) and stop. If the event
is present in both the medical record and the encounter data, proceed to data field validation.
Required Review: (Check one)
[ ] Office Visit - (excludes dental and mental health / substance abuse visits)
[ ] Office Visit - mental health / substance abuse
[ ] Office Visit - dental
[ ] Inpatient admission - (excludes mental health / substance abuse visits)
[ ] Inpatient admission - mental health / substance abuse
[ ] Other types of encounters as specified by the State (e.g., laboratory, pharmacy, physical
therapy). Specify:_______________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0786. The time required
to complete this information collection is estimated to average 1,591 hours per response for all activities, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850

EQR Protocol 4 Attachment B
Medical Record Review Worksheet
September 2012

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EQR Protocol 4 Attachment B
Medical Record Review Worksheet
September 2012

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Table 2: Data Field Validation
Data Field Validation
Diagnosis Codes and Descriptions
Diagnosis Code (from
encounter data)

Diagnosis Description (from
medical record)

Match

No Match

Procedure Description (from
medical record)

Match

No Match

Description (from medical
record)

Match

No Match

a.
b.
c.
Procedure Codes and Descriptions
Procedure Code (from
encounter data)
a.
b.
c.
Revenue Codes and Descriptions
Revenue Code (from
encounter data)
a.
b.
c.
Notes: (Describe nature of inconsistencies, such as missing coding specificity; up-coding; incomplete
recording of diagnoses or procedures in encounter data, etc.)

NOTE: The EQRO should tailor this form to include all data fields under review.

EQR Protocol 4 Attachment B
Medical Record Review Worksheet
September 2012

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Table 3: Medical Record Review
Medical Record Results Summary Sheet
Research Question:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Sample Size:___________

Sampling Methodology:_______________________________

Record of Substitutions (List substitutions and reasons):
Original Record
1.
2.
3.
4.

Replacement Record

Reason

Results:
Record Reviewed

Event
present in
medical
record?
(Y/N)

Event
present in
encounter
data?
(Y/N)

Codes
Match?
(Y/N)

Notes on inconsistencies

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
NOTE: The EQRO should add rows to include total sample of records. It may add columns for each field
validated, or it may retain a single summary column for all fields validated (e.g., procedure codes,
diagnosis codes, revenue codes, etc.)

Error Rate:________ (Total records with errors/Total records in sample)
Reviewer Summary of Findings:

END OF DOCUMENT

EQR Protocol 4 Attachment B
Medical Record Review Worksheet
September 2012

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