Medical Record and Documentation Standards
Medical records and related documentation must contain the information necessary to support claims submitted by the provider for services rendered and in support of quality improvement activities . Medical information and documentation must meet the industry standards as established by federal and state regulatory agencies , as well as accrediting organizations . Providers must :
• Maintain a single , permanent medical record that is detailed , legible , organized , current , and comprehensive , and available for each patient visit
• Providers must establish policies and procedures for the protection , storage and maintenance of medical records , whether paper or electronic . Safeguards must be implemented to prevent unauthorized access or alteration , loss , destruction , or tampering
• Medical records must be maintained in a confidential manner , periodic training must be provided to office staff regarding confidentiality and usage
• All entries must be legible , dated , and identify the author and their credentials when applicable . It should be apparent from the documentation which individual provided a given service
• Clearly label or document subsequent charges to a medical record entry by including the author or the change and date of change . The provider must also maintain a copy of the original entry
• Documentation should be created at the time of service or shortly thereafter
• Cite medical conditions and significant illnesses on a Problem List , and document clinical findings and evaluation for each visit that : o Emphasize in notes and charts all known medication allergies and adverse reactions , as well as if the member has no known allergies or adverse reactions o Medication records must reflect the name of the medication , dosages , and the rationale for their application . Over the counter medications utilized by the member must also be listed o Document all pertinent medical history , chief complaints , significant issues , chronic illnesses , accidents , and surgical procedures o Records reflect all services provided , ancillary services / tests ordered , and all diagnostic / therapeutic services referred by the provider
61