Medical Record Standards
1. Organized, individual medical records
2. Organized filing system for medical records
3. Confidentiality/security of medical information assured
4. Release of information documents signed
5. Presentation of patient rights and responsibilities to member documented
Chart Elements (Chart Documentation Captures Core Elements Below)
6. Allergies and/or adverse reactions to medications or, if applicable, no know allergies are noted
7. Personal health history includes complete medical and behavioral health history
8. Visit notes include: History and description of presenting problems, mental status evaluation, physical status evaluation if appropriate, risk assessment including potential harm to self or others
9. Plan of care
10. Notes indicate follow up to plan of care
11. Evidence of coordination of care, if the member has co-morbid medical and behavioral health conditions
12. A copy of a written discharge plan that was provided to the member is included in chart