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 Practitioners (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. PCP’s and Specialists also receive a copy of the standards at the time of their initial and subsequent site visit.

The Plan performs a medical record review every two years on a random selection of Providers. The medical records are audited using these standards.

The following is a list of our standards:

Elements in the medical record are organized in a consistent manner, and the records are kept secure and confidential.
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.
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 abuse (or lack thereof) is recorded when pertinent to proposed care and/or risk screening.
An updated problem list is maintained.
For patients 65 years or older, document discussions of a living will or other advance directive.
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.
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’s Preventive Health Guidelines.
An immunization record appropriate history has been made in the medical record.
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.
Document all therapies and other prescribed regimens.
Document disposition and follow-up.
Document referrals and results.
Services provided as per the Patient-Centered Service Plan for Participants who have one.
Service coordination contact notes as applicable.

Practitioners are required to achieve a medical record score of 90% or greater to meet the Plan's standards. Practitioners that do not achieve the score of 90% will have re-audit within 120 days to ensure that the deficiencies are corrected. Results for practitioners not achieving a passing score of 90% on the re-audit are presented to the Plan’s Credentialing Committee for review and recommendations. The Practitioner 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 practitioner 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 (EMR) must be made available in paper form upon request. Medical records should be organized in a manner that allows for easy retrieval.