All physicians maintain medical records in accordance with the most recent National Committee for Quality Assurance (NSQA) standard. A manner that is current, detailed, and organized permits effective patient care and quality review and maintains confidentiality.
Note All entries must be legible to someone other than the writer.
This includes the following steps:
1. File the medical record using a systematic method for easy retrieval, such as alphabetical or numerical filing, preferably color-coded to allow for prompt retrieval of medical records and availability to the physician at each patient encounter.
2. Use the medical record system to allow for the tracking of the record when it is out of the filing system and to have a system for the incorporation of information in the chart between visits as well as a system for the archiving of purged data.
3. Ensure medical records are inaccessible to patients and other unauthorized persons and are maintained to guard against unauthorized disclosure of confidential information.
4. Use contracts with physicians that explicitly state expectations about the confidentiality of patient information and records.
5. When a patient changes to a new Primary Care Physician (PCP) (prior to the patient’s first visit with the new PCP), transfer medical records to the new physician. Safeguard the privacy of the medical record in transit. Deliver requested information in a timely manner to ensure continuity of care.
6. Maintain a medical record for each patient (not one per family).
7. Securely anchor all pages in the record, and file all pages chronologically.
8. Ensure each page in the record contains the patients name or patient ID number for patient identification.
9. Regularly update personal/biographical and demographic data including age, sex, address, telephone number, and marital status.
10. Maintain a copy of a consent to treat form in the medical record.
11. Document all aspects of patient care, including use of ancillary services.
12. Date all entries.
13. Identify the author of all entries, including title.
14. Ensure the records are legible, documented accurately, and documented in a timely manner.
15. Ensure each medical record contains the following:
•The patient’s name, address, date of birth, Social Security number, subscriber identification numbers, work and home telephone numbers, emergency contact, marital status, employer, the name of any legally authorized representative, and health questionnaire (dated and initialed by the PCP) to establish baseline data.
•A copy of a consent to treat form.
•Physical examinations and follow-up care with appropriate subjective and objective information obtained from the presenting complaints.
•Appropriate vital signs documented at each visit.
•Allergies and adverse reactions prominently noted on the record. If the patient has no allergies, note absence of allergies (no known allergies or NKA).
•Past medical history (for patients seen 3 or more times), including serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history related to prenatal care, birth, operations, and childhood illnesses.
•For patients 13 years and older, appropriate notation concerning the use of cigarettes, alcohol, and substances. For patients seen 3 or more times, document any substance abuse history.
•Documentation of appropriate use of consultants. If a consultation is requested, the consultant adds a note in the medical record.
16. Prominently note allergies and adverse reactions on the record. If the patient has no allergies, note absence of allergies (no known allergies or NKA).
17. Document a record of immunizations for all age groups. For immunizations you must document the lot number, date, time, site, and education given to parents.
18. For pediatric records (age 12 and under), ensure there is an immunization record, plotted growth charts, and documentation of neurological milestones.
19. For patients 12 years and older, you must include information provided concerning cigarettes, alcohol, substance use, and anticipatory guidance.
20. For females, ages 47-57, you must include evidence that the physician has communicated to them their options for dealing with menopause.
21. For medical records for diabetic members, you must include (1) the medical record that contains a diabetes flow sheet, (2) records of the physician using established diabetes practice guidelines, (3) records containing annual screenings for Hemoglobin Alc, LDL-C, Microalbuminuria, and (4) records containing evidence of annual optometrist/ophthalmologist referral and reason for the referral.
22. For medical records for documented heart disease, you must include (1) records containing a problem list noting the diagnosis of hypertension, including the date of diagnosis as an entry, (2) records containing a blood pressure reading after the date of entry of the diagnosis of hypertension on the problem list, and (3) records containing evidence of an LDL-C screening performed after discharge for one of the following conditions/procedures: acute myocardial infarction, coronary artery bypass graft, or percutaneous transluminal coronary angioplasty.
23. List all medications currently used. Medication information must include name, date prescribed, dosage, frequency, and duration. Medications given on-site must list name, dosage, date, and site given.
24. Identify current problems, significant illnesses, medical conditions, and health maintenance concerns in the medical record.
25. Note the reason (chief complaints) for the visit.
26. Include a medical history and physical examination with appropriate subjective and objective information for the presenting complaints.
27. Add diagnostic information and a plan of treatment for each visit. For more information, see Office Encounter Forms.
28. Document treatments, procedures, and tests, including results.
29. Indicate if there is a specific follow-up date for a return visit or other follow-up plans for each encounter.
30. Add referrals to a specialist, a hospital, or to home health care with corresponding specialist consultant reports, discharge summary, or home health reports, as applicable.
31. Provide evidence that there is continuity and coordination of care between the primary and specialty physicians.
32. Physicians must sign or initial lab, pathology, and x-ray reports filed in the chart to signify that they have been reviewed.
33. Ensure consultation and abnormal lab and/or imaging results have an explicit notation in the record for follow-up plans.
34. Physicians must include their review in all discharge summaries, emergency department reports, specialty consultation reports, and specialty follow-up care notes. The documents must be filed in the chart within two weeks of service.
35. Add evidence of follow-up on failed appointments.
36. Document patient health education, recommendations, instructions, and referrals.
37. Provide evidence that preventive services have been performed and done so appropriately.
38. Document whether the patient has executed an Advance Directive, which is a written instruction such as a Living Will or Durable Power of Attorney for health care relating to the provision of health care when the individual is incapacitated, or a notation that information about Advance Directives was given to the patient as required by federal law. For more information, see Advance Directives.
39. If applicable, file a human sterilization consent form (PM330) in the patient’s medical record.
40. Document initial health assessments and Child Health and Disability (CHDP) screenings.
41. Include a copy of the CHDP PM 160 form in the medical record (CHDP Physicians only).
42. Complete the Health Behavior Risk Assessment for each patient during the first appointment with the Primary Care Physician (Medi-Cal members only).
43. Include standard forms for documenting prenatal care. Forms include documentation of medical, psychosocial, nutritional, and educational assessments, interventions, and referrals for prenatal services (Comprehensive Prenatal Services Program [CPSP] Providers only).
44. Store adult medical records for seven (7) years. Store pediatric medical records until the child is 21 years of age per current state and federal requirements.