Medical Record Documentation Guidelines for Practitioner Offices

Consistent and complete documentation in the medical record is an essential component of quality patient care.  In addition to compliance with basic and sound principles of complete record keeping, records must document a process of medical care and patient education.

View the complete Documentation Review Standard.

Jump down to Systems for Handling Records
Jump down to Documentation in Medical Records
Jump down to Confidentiality of Medical Records


Systems for Handling and Keeping Medical Records

• The practitioner office must maintain separate medical records for each member seen.
  
• The medical record must be part of an organized medical record-keeping system and easily retrievable for review.
• Medical records must be retained in accordance with state law.
• Medical records will be made available to Priority Health as indicated in the provider contract.
• When a member changes his/her Primary Care Practitioner, his/her medical records or copies must be forwarded to the new Primary Care Practitioner within 10 working days from receipt of the request.
• Medical records must be stored away from patient care areas.

Documentation in Medical Records

• Each page in the member record must contain the patient's name or ID number.
• The member record must include the following personal/biographical data:
  • Member address
  • Employer
  • Home and work phone numbers
  • Gender
  • Date of birth
  • Emergency contact person/phone number
  • Marital status
• Author identification, either by a hand-written signature, initials, or unique electronic identifier, for all entries.
  
• Dates for all entries.
• The record is legible to someone other than the writer.
• Significant illnesses and medical conditions are indicated on a problem list.
• Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is noted in the record.
• A past medical, social, and family history for patients seen more than three times is easily identified and includes serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses.
• For patients 14 years and older seen more than three times, there is appropriate notation concerning the use of cigarettes (12 years and older), alcohol, substance abuse, and STDs.
• The history and physical exam identifies and records appropriate subjective and objective information pertinent to the patient's presenting complaints. The complete physical exam includes system review.
• Laboratory and other studies are ordered as appropriate and documented.
• Working diagnoses, consistent with findings, are documented.
• Treatment plans are specific and consistent for diagnoses and include medications and prescriptions.
• Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls, or visits. The specific time period for return is noted in weeks, months or as needed.
• Unresolved problems from previous office visits are addressed in subsequent visits.
• Notes from consultants to which the patient has been referred are in the record.
• Records of ancillary care provided are included.
• Consultation, lab, and imaging reports in the chart are initialed (handwritten or electronic) and dated by the ordering practitioner to signify review. Consultation and abnormal lab and imaging study results have an explicit notation in the record of follow-up plans. Electronic signatures must be password protected.
• There is no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic problem.
• An immunization record is up-to-date for children. An appropriate history has been made in the medical record for adults.
• There is evidence in the medical record whether a patient has executed an advance directive.
  
• Documentation of an advance directive must be in a prominent part of the medical record.
  
• There is evidence that preventive screening and services are offered to members in accordance with Priority Health's Preventive Health Care Guidelines.
• There is no evidence of under-utilization or over-utilization of consultants.

Confidentiality

• Each practitioner must maintain a Notice of Privacy Practice in order to maintain HIPAA compliance.
• Employees must protect computer-processed patient or provider care information with the same diligence as the original health record (e.g., identification of authorized users; use of security codes; and location of computer facility in a limited access area).
• The office must maintain back-up files for all current information system data off-site or in a separate secure geographic location.
• As applicable, the office must obtain written agreements from the computer vendors involved with patient or practitioner health care data that mandate the security of computerized data classified as confidential, and specify the methods by which employees are to handle and transport such information.
• Medical records must be stored away from patient care areas, in a place where persons other than staff cannot view them.
• Employees must maintain confidentiality at all points: during collection of the information, when and where it is stored with limited access and disclosure including eventual disposal.

These guidelines encompass standards from:

• National Committee for Quality Assurance
• Office of Financial and Insurance Services
• Medicaid's Early and Periodic Screening, Diagnosis and Treatment (EPSDT) criteria