Medical Record Documentation Standards

• Confidentiality and security of medical information assured
• Evidence of critical lab value reporting process to physician
• Medical record documents past medical history, physical exam, allergies, consent and advanced directive
• Release of information documents signed

• Organized, individual medical records 
• Organized filing system for medical records 
• Confidentiality and security of medical information assured 
• Release of information documents signed 
• Presentation of patient rights and responsibilities to member documented 

Chart elements 

Documentation captures these core elements: 

• Allergies and adverse reactions to medications or, if applicable, no know allergies are noted 
• Personal health history includes complete medical and behavioral health history 
• Visit notes include history and description of presenting problems, mental status evaluation, physical status evaluation if appropriate and risk assessment, including potential harm to self or others 
• Plan of care 
• Notes indicate follow up to plan of care 
• Evidence of coordination of care if the member has comorbid medical and behavioral health conditions 
• A copy of a written discharge plan provided to the member is included in the chart 

• Confidentiality and security of medical information assured 
• Release of information documents signed 
• Records note whether or not adult patient has signed an advanced directive 
• Patient rights and responsibilities are posted in an area likely to be seen by the patient 

Chart elements  

Documentation captures these core elements: 

• Medications, allergies and adverse reactions, or, if applicable, no know allergies are noted. 
• A past medical history for members seen on at least three visits that includes serious accidents, operations and illnesses 
• A past medical history for members younger than 18 years that includes prenatal care, birth information, operations and illnesses 
• A problem list that notes significant illnesses and medical conditions. 
• Visit notes include reason for visit, physical findings, appropriate diagnostic test and plan of care to include follow up. 

• Confidentiality and security of medical records is assured.
• Records document status of advanced directive.
• Records document release of information signed.
• Patient rights and responsibilities document provided at start of care.
• Registered nurse initial evaluation, plan of care and re-evaluation within 60 days.
• RN oversight of licensed practical nurse and certified nursing assistant documented in record.
• Evidence of coordination of care with physician.

• Confidentiality and security of medical information assured
• Record includes past medical history, physical exam, allergies, consent and advanced directive.
• Release of information documents signed.
• Pre-operative, surgical time out and discharge protocols available
• Patient safety policies and procedures, including fall risk and skin breakdown.

Five core items are bolded below.

• There is an organized medical record filing system.
• Personal and biographical data are present and include the date of birth, sex, marital status, address, employer, home and work telephone numbers.
• Every page contains patient identification.
• All entries are dated.
• Each entry contains author identification (signed or initialed by practitioner). Electronic signatures are acceptable provided authorization for its use is included in the signature line.
• A family and social history is noted in the record.
• The medical record is legible to the reviewer.
• Medication allergies and adverse reactions or, if applicable, no known allergies are noted.
• There is a past medical history present for members seen on at least three visits that includes serious accidents, operations and illnesses. Members  age 18 years or younger, have a past medical history that includes prenatal care and birth information, operations and illnesses.
• A problem list is present and notes significant illnesses and medical conditions.
• Members at least age 12, and who have been seen on at least three visits, will have notations that address smoking, ethyl alcohol and substance use.
• Immunization records are current or note indicates immunizations are up to date.
• There is a medication list present.
• Visit notes include a reason for the visit, physical findings, appropriate diagnostic tests and a plan of treatment.
• Follow-up care and plans are documented.
• Unresolved problems are addressed in subsequent visits.
• The practitioner initials consult, ancillary services, lab and imaging study reports.
• If the member is hospitalized the record will include the following: operative report, if applicable, and hospital discharge summary.
• There is evidence of continuity and coordination of care between primary and specialty practitioners.
• Preventive services are provided in accordance with BlueLincs HMO^SM guidelines.
• Confidentiality policy regarding personal health information and informed consent for release of records utilized.

• Written policy and procedure for medical record confidentiality and management
• Organized, individual medical records
• Organized filing system for medical records
• Confidentiality and security of medical information assured
• Release of information documents signed
• Patient rights that are communicated prior to service and understandable to the patient
• Transitions of care and discharge planning clearly documented

• Organized, individual medical records
• Organized filing system for medical records
• Confidentiality and security of medical information assured
• Release of information documents signed
• Record notes whether adult patient has signed an advanced directive
• Plan of care developed within seven days of admission and updated interdisciplinary review and revision as appropriate
• Patient safety assessments, such as fall risk and skin breakdown, completed per facility policy
• Patient rights and responsibilities documented