Ensure accurate medical records for patients with high blood pressure

Hypertension is among the most common conditions seen in the primary care setting. If left untreated, it can lead to myocardial infarction, stroke, renal failure and even death.

Consistent updates in the medical records can help you and your patients keep blood pressure under control.

Here are important things to keep in mind when caring for and updating medical records in accordance with HEDIS^® specifications for your hypertensive patients:

• To confirm diagnosis of hypertension, a notation of hypertension must appear in the medical record during an outpatient visit on or before June 30 of each year.
  
  Examples of notation include: Hypertension, HTN, High BP, Elevated BP, Borderline HTN, Intermittent HTN, History of HTN, Hypertensive vascular disease, Hyperpiesia or Hyperpiesis.

• A representative blood pressure is the most recent blood pressure reading taken during the measurement year (by Dec. 31). It occurs after the date of service in which the diagnosis of hypertension occurred.
• If multiple readings occur in a single visit, the lowest systolic and lowest diastolic is the representative blood pressure and determines blood pressure control.
• Repeat all elevated blood pressures later in the visit. Typically, blood pressure will decrease once the patient has been in the exam room a while.
• Don’t round manual blood pressure readings. Rounding up just a few points can make a patient cross the line from controlled to uncontrolled.
• A blood pressure reading must be taken and documented in the chart during the same visit in which you assess the patient for hypertension and again at subsequent visits.

• Self-reported blood pressure readings taken by your patient aren’t acceptable as a diagnosis of hypertension.

Blood pressure control is defined as:

• Patients age 18 to 59 whose blood pressure was under 140/90
• Patients age 60 to 85 with a diagnosis of diabetes whose blood pressure was less than 140/90
• Patients age 60 to 85 without a diagnosis of diabetes whose blood pressure was less than 150/90

For diabetic patients

If lifestyle changes alone aren’t effective in keeping a diabetic patient’s blood pressure controlled, you may need to add anti-hypertensive medications to the regimen.

Best practice for patients who have hypertension associated with diabetes is to initiate pharmacologic anti-hypertensive treatment. This includes an angiotensin converting enzyme inhibitor or angiotensin receptor blocker unless there are specific pre-existing contraindications.

Educate your patients about the importance of taking their recommended medications regularly and discuss possible side effects.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

None of the information included herein is intended to be legal advice and as such it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.