Medical Record Documentation Standards
1. There is an organized medical record filing system.
2. Personal/biographical data is present and includes the date of birth, sex, marital status, address, employer, home and work telephone numbers.
3. Every page contains patient identification.
4. All entries are dated.
5. 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.
6. A family/social history is noted in the record.
7. The medical record is legible to the reviewer.
*8. Medication allergies and/or adverse reactions or, if applicable, no known allergies are noted.
*9. 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.
*10. A problem list is present and notes significant illnesses and medical conditions.
11. Members > 12 years, and who have been seen on > 3 visits, will have notations that address smoking/ETOH/substance abuse.
12. Immunization records are current or note indicates immunizations are up to date.
13. There is a medication list present.
*14. Visit notes include a reason for the visit, physical findings, appropriate diagnostic tests, and a plan of treatment.
*15. Follow-up care and plans are documented.
16. Unresolved problems are addressed in subsequent visits.
17. The practitioner initials consult, ancillary services, lab, and imaging study reports.
18. If the member is hospitalized the record will include the following: operative report (if applicable) and hospital discharge summary.
19. There is evidence of continuity and coordination of care between primary and specialty practitioners.
20. Preventive services are provided in accordance with BlueLincs HMOSM guidelines.
21. Confidentiality policy regarding PHI and Informed Consent for release of records utilized.
*Five core items