Medical Record Standards

Below are our standards of care for medical records and documentation.

  • Ambulatory dialysis center

    • 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
  • Behavioral health care clinic

    • 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 
  • Health care clinic

    • 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. 
  • Home health and hospice

    • 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.
  • Hospital and ambulatory surgery center

    • 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.
  • Practitioner

    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 HMOSM guidelines.
    • Confidentiality policy regarding personal health information and informed consent for release of records utilized.
  • Residential treatment facility

    • 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
  • Skilled nursing facility

    • 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