Medical Record Standards
1. Confidentiality and security of medical information assured
2. Release of information documents signed
3. Records note whether or not adult patient has signed an Advanced Directive
4. Patient rights and responsibilities posted in area likely to be seen by patient
Chart Elements (Chart Documentation Captures Core Elements Below)
5. Medications, allergies, and/or adverse reactions, or, if applicable, no know allergies are noted.
6. There is a past medical history present for members seen on ≥ 3 visits, which includes serious accidents, operations and illnesses; Member < 18 years, have a PMH present, which includes prenatal care, birth information, operations and illnesses.
7. A problem list is present and notes significant illnesses and medical conditions.
8. Visit notes include reason for visit, physical findings, appropriate diagnostic test and plan of care to include follow up.