Medical Record Standards

Complete and consistent documentation in patient medical records is an essential component of quality patient care. The Plan adheres to medical record requirements that are consistent with national standards on documentation and applicable laws and regulations. Compliance with the Plan’s medical record standards and preventive health guidelines are evaluated, not less than every 2 years, based on a random selection process and/or as determined by the Plan for Primary Care Providers (PCP), Obstetrics and Gynecology (OB/GYN) Providers, high-impact/high-volume specialists, and other Providers as deemed appropriate. Providers are notified of Plan medical standards through the Provider newsletter and website. PCPs and Specialists also receive a copy of the standards at the time of their initial and subsequent site visit.

The Plan performs an annual medical record review on a random selection of practitioners. The medical records are audited using these standards.

The following is a list of our standards:

Medical records are organized in a consistent manner, and the records are kept secure, confidential, and only authorized staff have access.
Staff receive training in Member information confidentiality.
Patient's name or identification number is included on each page of record.
All entries are legible, initialed, or signed and dated by the author.
Personal and biographical data are included in the record.
All services are provided by a PCP or allied health professional under the supervision of a PCP. Current and past medical history and age-appropriate physical exams are documented including serious accidents, operations, and illnesses.
Allergies and adverse reactions are prominently listed or noted as "none" or "NKA".
Information regarding personal habits such as smoking and history of alcohol use and substance use (or lack thereof) is recorded when pertinent to proposed care and/or risk screening.
An updated problem list is maintained. Documentation of discussions of a living will or other advance directive for patients 65 years or older.
Patient's chief complaint or purpose for visit is clearly documented.
Clinical assessment and/or physical findings are recorded. Appropriate working diagnoses or medical impressions are recorded for each visit.
Plans of action/treatment are consistent with diagnosis.
There is no evidence the patient is placed at inappropriate risk by a diagnostic procedure or therapeutic procedure.
Unresolved problems from previous visits are addressed in subsequent visits.
Follow-up instructions and time frame for follow-up or the next visit are recorded as appropriate.
Current medications are documented in the record, and notes reflect that long-term medications are reviewed at least annually by the Network Provider and updated as needed.
Health care education provided to patients, family members or designated caregivers is noted in the record and periodically updated as appropriate.
Screening and preventive care practices are in accordance with the Plan Preventive Health Guidelines.
An immunization record is up to date (for Members under 21 years of age) or an appropriate history has been made in the medical record (for adults).
Requests for consultations are consistent with clinical assessment/physical findings.
Laboratory and other studies are ordered, as appropriate.
Laboratory and diagnostic reports reflect Network Provider review.
Patient notification of laboratory and diagnostic test results and instruction regarding follow-up, when indicated, are documented.
There is evidence of continuity and coordination of care between PCPs and Specialists.
Providers are required to achieve a medical record score of 90% or greater to meet the Plan's standards.
Providers that do not achieve the score of 90% will have re-audit within 120 days to ensure that the deficiencies area corrected.
Results for Providers not achieving a passing score of 90% on the re-audit are presented to the Plan’s Credentialing Committee for review and recommendations. The Provider will be notified of the Committee's recommendations within ten (10) business days. The Plan’s Quality Management Department will provide oversight of Committee's recommendations and any Correction Action Plan’s requested for specific Provider practices.

Medical record retention responsibilities

Medical records must be preserved and maintained for a minimum of ten (10) years from termination of the Health Care Provider’s agreement with the Plan or as otherwise required by law or regulatory requirement. Medical records may be maintained in paper or electronic form; electronic medical records must be made available in paper form upon request. Medical records should be organized in a manner that allows for easy retrieval.