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Chapter 9: Medical Records

You are required to keep complete and orderly medical records, which fosters efficient and quality member care. You are subject to our periodic quality medical record review. The review determines compliance to the following requirements:

Confidentiality of Record

Office policies and procedures exist for:

  • Privacy of the member medical record.
  • Initial and periodic training of office staff about medical record privacy.
  • Release of information.
  • Record retention.
  • Availability of medical record if housed in a different office location.

Record Organization

  • Have a policy that provides medical records upon request. Urgent situations require copies be provided within 48 hours.
  • Maintain medical records in a current, detailed, organized and comprehensive manner. The records should be:
    • In order.
    • Fastened, if loose.
    • Separate for each member.
    • Filed in a manner for easy retrieval.
    • Readily available to the treating care provider where the member generally receives care.
    • Promptly sent to specialists upon request.
  • Medical records are:
    • Stored in a manner that helps ensure privacy.
    • Released only to entities as designated consistent with federal requirements.
  • Kept in a secure area accessible only to authorized personnel.

Procedural Elements

Medical records are readable*

  • Sign and date all entries.
  • Member name/identification number is on each page of the record.
  • Document language or cultural needs.
  • Medical records contain demographic data that includes name, identification numbers, date of birth, gender, address, phone number(s), employer, contact information, marital status and an indication whether the member’s first language is something other than English.
  • Procedure for monitoring and handling missed appointments is in place.
  • An advance directive is in a prominent part of the current medical record for adults 18 years and older, emancipated minors and minors with children. Adults 18 years and older, emancipated minors and minors with children are given information about advance directives.
  • Include a list of significant illnesses and active medical conditions.
  • Include a list of prescribed and over-the-counter medications. Review it annually.*
  • Document the presence or absence of allergies or adverse reactions.*

History

An initial history (for members seen three or more times) and physical is performed. It should include:

  • Medical and surgical history*
  • A family history that includes relevant medical history of parents and/or siblings
  • A social history that includes information about occupation, living situations, education, smoking, alcohol use, and/or substance abuse use/ history beginning at age 11
  • Current and history of immunizations of children, adolescents and adults
  • Screenings of/for:
    • Recommended preventive health screenings/tests
    • Depression
    • High-risk behaviors such as drug, alcohol and tobacco use; if present, advise to quit
    • Medicare members for functional status assessment and pain
    • Adolescents on depression, substance abuse, tobacco use, sexual activity, exercise and nutrition and counseling as appropriate

Problem Evaluation and Management

Documentation for each visit includes:

  • Appropriate vital signs (Measurement of height, weight, and BMI annually)
    • Chief complaint*
    • Physical assessment*
    • Diagnosis*
    • Treatment plan*
  • Tracking and referral of age and gender appropriate preventive health services consistent with Preventive Health Guidelines.
  • Documentation of all elements of age appropriate federal Early, Periodic, Screening, Diagnosis and Treatment (EPSDT).
  • Clinical decisions and safety support tools are in place to ensure evidence based care, such as flow sheets.
  • Treatment plans are consistent with evidence-based care and with findings/diagnosis:
    • Timeframe for follow-up visit as appropriate
    • Appropriate use of referrals/consults, studies, tests
  • X-rays, labs consultation reports are included in the medical record with evidence of care provider review.
  • There is evidence of care provider follow-up of abnormal results.
  • Unresolved issues from a previous visit are followed up on the subsequent visit.
  • There is evidence of coordination with behavioral health care provider.
  • Education, including lifestyle counseling, is documented.
  • Member input and/or understanding of treatment plan and options is documented.
  • Copies of hospital discharge summaries, home health care reports, emergency room care, practitioner are documented.

*Critical element

Screening and Documentations Tools

These tools were developed to help you follow regulatory requirements and practice.

On an ad hoc basis, we conduct a review of our members’ medical records. We expect you to achieve a passing score of 85% or better. To achieve this score, the medical records you maintain should contain an initial health assessment, including a baseline comprehensive medical history. This assessment should be completed in less than two visits, with ongoing physical assessments occurring on following visits. It should also include:

  • Problem list with:
    • Biographical data with family history.
    • Past and present medical and surgical intervention.
    • Significant medical conditions with date of onset and resolution.
    • Documentation of education/counseling regarding HIV pre- and post-test, including results.
  • Entries dated and the author identified.
  • Legible entries.
  • Medication allergies and adverse reactions (or note if none are known).
  • Easily known past medical history. This should include serious illnesses, injuries and operations (for members seen three or more times). For children and adolescents (18 years or younger), this includes prenatal care, birth, operations and childhood illnesses.
  • Medication record, including names of medication, dosage, amount dispensed and dispensing instructions.
  • Immunization record.
  • Tobacco habits, alcohol use and substance abuse (12 years and older).
  • Copy of advance directive, or other document as allowed by state law, or notate member does not want one.
  • History of physical examination (including subjective and objective findings).
  • Unresolved problems from previous visits addressed in subsequent visits; diagnosis and treatment plans consistent with finding.
  • Lab and other studies as appropriate.
  • Member education, counseling and/or coordination of care with other care providers.
  • Notes regarding the date of return visit or other follow- up.
  • Consultations, lab, imaging and special studies initialed by primary care provider to indicate review.
  • Consultation and abnormal studies including follow- up plans.

Member hospitalization records should include, as appropriate:

  • History and physical
  • Consultation notes
  • Operative notes
  • Discharge summary
  • Other appropriate clinical information
  • Documentation of appropriate preventive screening and services
  • Documentation of behavioral health assessment (CAGE-AID, TWEAK AND PHQ-9)

Find a Medical Record Documentation Standard sample here.