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Note on Medical Record Standards Documentation: Johns Hopkins HealthCare has established standards for primary care medical record documentation. Records must be maintained in a manner that is current, detailed and organized to facilitated communication, coordination and continuity of care. The standards address confidentiality, the availability of the medical record, and required content of the record. To ensure confidential care for members, the JHHC standards state that medical records are stored securely. Records must be easy to retrieve, but only authorized personnel should have access to them. In addition, staff is expected to receive training in member confidentiality. Compliance with these new standards will be monitored as part of our Quality Improvement Program.
Drug and alcohol abuse or dependence are common issues but are often under recognized in primary care settings. Utilizing a simple screening tool, such as the four question CAGE substance abuse assessment, is an easy yet effective way for the primary care provider to determine if substance abuse exists and needs to be addressed.
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