Medical Records Documentation/Preventive & Practice Guidelines
Medical Records Documentation
The following medical record standards apply to each enrollee’s record and will be used as a guide for the periodic on-site record reviews:
- Must contain identifying information on the enrollee, including name, enrollee Medicaid or member identification number, date of birth, sex and legal guardianship.
- Must be legible and maintained in detail as to permit an external reviewer to follow the progression of care.
- Contain a summary of significant surgical procedures, medical history, past and current diagnosis or problems, allergies, current medications and untoward reactions to drugs.
- All entries must be dated and signed by the appropriate caregiver.
- Must indicate the chief complaint or purpose of the visit; the objective findings of the practitioner; diagnosis or medical impression.
- Must indicate studies ordered, for example: lab, x-ray, EKG, and referral reports. Test results and findings of diagnostic studies need to be reviewed by the physician and added to the record in a timely manner.
- Must indicate therapies administered and prescribed.
- Must include the name and profession of practitioner rendering services, for example: M.D, D.O., O.D., including signature or initials of practitioner.
- Must include the disposition, recommendations, instructions to the patient, evidence of whether there was follow up, and outcome of services.
- Must contain a complete immunization history.
- Must contain information on smoking, alcohol/substance abuse (14 years or older).
- Must contain summaries of all emergency services and care and hospital discharges (such as Discharge Summary) with the appropriate medically indicated follow-up.
- Documentation of referral services and result of referral and/or consultation reports.
- Documentation of all services provided, including but not necessarily limited to, family planning services, preventive services and services for the treatment of sexually transmitted diseases.
- Reflect the primary language spoken by the enrollee and any translation needs of the enrollee.
- Identify enrollees needing communication assistance in the delivery of healthcare services
- For enrollees 18 years and older: Documentation that the enrollee was provided written information concerning the enrollee’s rights regarding advance directives (written instructions for living will or power of attorney) and whether or not the enrollee has executed advance directives. The execution or waiver of advance directives does not constitute a condition of treatment.
- Behavioral health records must include – for each services provided, clear identification as to:
- The physician or other service provider
- The date of service
- The units of services provided AND
- The type of service provided
Preventive Guidelines
Clinical Practice Guidelines Related to Disease Management Programs
- Diabetes Mellitus
- Asthma
- Congestive Heart Failure
- Hypertension
- HIV/AIDS
