Medica Administrative Manual > Provider Responsibilities > Medical Record Guidelines
Medical Record Guidelines
Medica has developed and adopted the following guidelines for Medica health care providers to follow for documentation in members’ medical records. Guidelines are based on the standards and regulations promulgated by the state governments within the Medica service area and:
- Centers for Medicare & Medicaid Services (CMS)
- Institute for Clinical Systems Improvement (ICSI)
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
- Medica Clinical Guidelines
- National Committee for Quality Assurance (NCQA)
- The American Health Information Management Association (AHIMA)
- The practicing medical community
- US Preventative Services Task Force (USPSTF)
Purpose
Medica adopted these guidelines to improve continuity and quality of patient care by assuring timely, legible, accurate and comprehensive documentation of patient-provider interactions. Well-documented medical records, whether electronic or on paper, facilitate communication, coordination and continuity of care, as well as promoting efficiency and effective treatment.
Policy
Medical records belonging to Medica members, electronic or paper, communicate the member’s past medical treatment, past and current health status and plans for future health care. Prior pertinent medical record information is available to the attending practitioner when a medical judgment is made. Medical records are organized in a consistent manner to permit efficient information retrieval. Medical records are used in a manner that maintains the member’s confidentiality. Records are stored in a secure fashion.
Scope
This policy applies to all health care providers contracted to serve Medica members.
Record Management
The medical record is maintained to ensure that:
- Confidentiality of the medical records is maintained according to existing law through policies and procedures for protecting medical record confidentiality and release of information. Medical records are stored in a secure area that is inaccessible to unauthorized individuals, as defined by the clinic. Medical records and patient reports are processed (completed, transported, filed, stored, etc.) in a manner identifiable to clinic staff only.
- Records are retrievable. A single, permanent medical record is maintained for each patient. The clinic has a system in place by which the patient’s complete medical record is available for all routinely scheduled office visits. Contents of a paper medical record are affixed and organized in a consistent manner.
- Continuity of care is maintained through policies and procedures to include:
- Documentation of all treatment-related telephone contacts.
- Documentation of after-hours patient/physician contact.
- A process to review failed appointments, determine necessity for patient contact and follow-up as necessary.
- A process to review and, as needed, arrange for follow-up to laboratory studies, X-ray procedures, consultations, ER visits, hospitalizations or other care not directly provided by and/or documented in the chart by clinic staff.
- Documentation of communication between specialists and the primary care provider.
- Documentation of communication between ancillary services (PT, OT, home care,etc.), prescribing provider and/or the primary care provider.
- The medical record contains patient demographic information:
- Patient name and/or identification number on every page
- Date of birth
- Address
- Marital status
- Occupational history
- Home and work phone numbers
- Name and telephone number of emergency contact
- All entries in the medical record are dated and identify the author. Author identification may be a handwritten signature, unique electronic identifier or initials.
- The provider’s policies and procedures stipulate that physicians use their own IDs and passwords to enter the electronic medical record (EMR) to sign medical records.
- For handwritten signatures or initials, there is a signature log containing printed full name, signature, initials and credentials for clinical staff (providers, nurses, CMS’s, X-ray techs, lab techs, etc.). For purposes of CMS audits, there is either a signature log available for illegible signatures or, for EMR’s, the clinic is able to produce documentation for the full name and credentials of any staff.
- Entries are legible by someone other than the author.
- All pages in the medical record contain patient identification.
- An up-to-date problem list cites both chronic and acute conditions that affect patient management. The problem list includes dates of onset and resolution.
- The presence/absence of allergies/adverse reactions is documented in a consistent, prominent location. If the patient has no known allergies or adverse reactions, this is noted.
- Past medical history is easily identified and includes serious illnesses, injuries and operations (for patients seen three or more times). For children and adolescents (18 years and younger), past history relates to prenatal care, birth, operations and childhood illnesses.
- Medication record includes name of medication, dosage, amount dispensed and dispensing instructions and is updated at every visit. The medication list should include over-thecounter medications.
- Immunizations are documented on a separate immunization record.
- Documentation of family and social histories is present in the record and updated at least every five years.
- Smoking status (over 11 years of age) or exposure to second-hand smoke is prominently displayed in the record. If the patient is a smoker, including e-cigarettes, or exposed to second-hand smoke, advice regarding smoking cessation is documented at every visit.
- Alcohol and substance use and abuse are documented.
- Patient hospitalization records, placed in the medical record within three weeks of discharge, include as appropriate:
- History and physical
- Consultation notes
- Operative notes
- Discharge summary
- Other appropriate clinical information
- All provider notes (as listed above) need to have appropriate signature along with credentials
- Consultation, lab, imaging and special studies reports are filed in the medical record and initialed by the primary care physician to indicate review. Consultation and abnormal studies contain notation in the record for follow-up plan, as needed.
- Specialty consultation or surgical center visit reports are signed and placed in the medical record within three weeks of the visit.
- For all adult patient 18 years of age and older, there is a notation in the medical record that the patient has or has not executed an advance directive. If the member has an advance directive, a copy needs to be in the medical record. If the member (age 65 and older) does not have an advance directive, there needs to be documentation by the provider of a discussion annually with the date the discussion occurred.
- Patient encounter documentation includes:
- History and physical examination containing subjective and objective findings pertinent to the pertinent complaint.
- Unresolved problems from previous visits addressed in subsequent visits.
- Diagnosis consistent with findings.
- Treatment plan consistent with diagnosis.
- Lab and other studies ordered as appropriate.
- Patient education and counseling.
- Coordination of care, as appropriate, with other agencies.
- Notation regarding return visit or other needed follow-up care for each encounter (time of return is noted in days, weeks, months, years or as needed).
- All appropriate preventive screening and services are documented. Refer to Medica's clinical guidelines for comprehensive guidelines on periodic health assessment and preventive screening.
Documentation for Risk Adjustment
Medica expects participating providers to follow the ICD-10-CM Official Guidelines for Coding and Reporting. CMS and HHS use ICD codes to perform risk adjustment, calculating payment rates based on member demographics and presence and severity of chronic conditions. The medical record must support the ICD coding for the associated claim(s) by, at minimum:
- Documenting, all health conditions that coexist at the time of the encounter, to the highest level of specificity;
- Documenting impact to patient care treatment or management (e.g. assessment, evaluation, treatment, monitoring and/or referral); and
- Documenting all current health conditions not less than annually. Ongoing conditions do not “carry over” from past years and are assumed to have resolved if not reported on an annual basis.
Monitoring and Auditing
To comply with regulatory and accreditation requirements, Medica monitors participating providers’ medical record documentation by methods that include, but are not limited to:
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Claims validation: Medical record documentation is compared to submitted claims for consistency and accuracy.
- Focused review: Medica staff may review medical records on a case-by-case basis if specific issues are identified through quality of care case review, claim review, or other referral sources.
- HEDIS®: The Healthcare Effectiveness Data and Information Set (HEDIS®) is a standardized measurement set used to measure performance on important dimensions of care and service.
- Risk adjustment review (RA): Medica staff or designee may review medical records to meet risk adjustment requirements.
- Risk Adjustment Data Validation (RADV): Medica staff may review records to validate RA eligible visits based on claims.
All participating providers are expected to comply with requests for medical records made by Medica. Providers must allow access to the complete electronic or hard copy medical record, including all flow sheets and scanned documentation, for the time period specified by the requestor.
The performance threshold for each standard varies based on the specific audit and previous scores. If a document scores below the threshold on any standard surveyed, the provider is required to implement a Corrective Action Plan (CAP) for the unmet standard(s). For those reviews requiring CAP’s, thresholds will be listed on the Corrective Action Plan (CAP) request each year.