MPM_Admin No. Primary Care Providers can document historical or member-reported services without any supporting documentation. (Specialists can only do so for measures that relate to their specialty.)
The information must be recorded, dated and maintained in the member’s legal health record. The name of the service or exclusion and the date is always required. The date must be specific enough to confirm that the service or exclusion was completed before the deadline for the measure. If measure compliance depends on the result (e.g. Controlling Blood Pressure) then the result must be documented as well. The documentation must be clear that the service was performed and not merely ordered.
