MEDICAL RECORD DOCUMENTATION STANDARDS

The health plans monitor our medical records to verify that we meet federal and state requirements. The following information is required:

1) Medication allergies and adverse reactions are noted in a consistent, prominent place. Otherwise, no known allergies or history of adverse reactions are noted.

2) Past medical history for patients seen more than three times is easily identifiable. This documentation includes serious accidents, operations and childhood illnesses.

3) For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses.

4) Documentation includes use of cigarettes, alcohol and substance abuse for members age 14 and older (substance abuse history is queried for members seen three or more times).

5) Problem lists are used for members with significant illnesses and/or conditions that should be monitored. A chief complaint and diagnosis or probable diagnosis is included.

6) The history and physical records include appropriate subjective and objective information pertinent to the member’s presenting complaints.

7) There is documentation of an exam appropriate for the condition.

8) All medication prescribed list name, dosage, frequency and duration.

9) Documentation of medications given in the clinical site include the date, time, medication’s name, dosage, route as well as the site given and whether the patient had a reaction to the medication.

10) Laboratory and other studies are appropriately ordered.

11) Treatments, procedures and tests and results are documented.

12) Working diagnoses are consistent with findings.

13) Treatment plans are consistent with diagnoses.

14) Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls or visits. The specific time of return is noted in weeks, months or as needed.

15) Unresolved problems from previous office visits are addressed in subsequent visits.

16) Member education, recommendation and instructions given are included.

17) Hospital discharge reports and health delivery organization reports are reviewed and initialed by the physician.

18) Pediatric members’ (age 14 and under) records have a completed immunization record or notation of immunizations up to date.

18) An immunization history has been noted for adults.

19) Preventive screening and services are offered and documented in accordance with clinical practice guidelines.

20) Under- and over utilization of consultants is evaluated.

21) Consultant notes are present as applicable.

22) Consultation, lab, x-ray, (etc.) reports are initialed by the physician upon review. Abnormal results include notation of follow-up plans.

23) There is no evidence that the member is placed at inappropriate risk by a diagnostic or therapeutic problem.

24) For adults over the age of 18 years, availability of Advance Directives is documented.