10 Medical Records
10.2 Member Medical Records Standards
We require medical records to be current, detailed and organized for effective, confidential patient care and quarterly review. Your medical records must conform to good professional medical practice and be permanently maintained and available at the primary care site for patient care.
Members are entitled to one copy of their medical record each year provided at no cost. Members or their representatives should have access to these records.
Medical records standards include:
1. Patient identification information — patient name or ID number must be shown on each page or electronic file
2. Personal/biographical data — age, sex, address, employer, home and work telephone numbers, and marital status
3. Date and corroboration — dated and identified by the author
4. Legibility - if someone other than the author judges it illegible, a second reviewer must evaluate it
5. Allergies — must note prominently:
6. Past medical history — for patients seen three or more times. Include serious accidents, operations, illnesses and prenatal care of mother and birth for children
7. Immunizations — a complete immunization record for pediatric members age 20 and younger with vaccines and dates of administration
8. Diagnostic information
9. Significant illnesses and chronic and recurrent medical conditions are indicated in the problem list on all member medical records
10. Report contributory and/or chronic conditions if they are monitored, evaluated, addressed or treated at the visit and impact the care.
11. All diagnoses reported on the claim should be fully documented in the medical record, and each diagnosis noted in the medical record should be reported in the claim corresponding to that encounter.
12. Medical information including medication and instruction to patient
13. Identification of current problems
14. Instructions including evidence the patient was provided basic teaching and instruction for physical or behavioral health condition
15. Smoking/alcohol/substance abuse — notation required for patients age 12 and older and seen three or more times
16. Consultations, referrals and specialist reports — consultation, lab and X-ray reports must have the ordering physician’s initials or other documentation signifying review; any consultation or abnormal lab and imaging study results must have an explicit notation
17. Emergencies — all emergency care and hospital discharge summaries for all admissions must be noted
18. Hospital discharge summaries — must be included for all admissions while enrolled and prior admissions when appropriate
19. Advance Directive — must document whether the patient has executed an Advance Directive such as a Living Will or Durable Power of Attorney