Medical Records Documentation

For Providers

Medical Records Documentation

The following medical record standards apply to each enrollee’s record and will be used as a guide for the periodic on-site record reviews:

  • Must contain identifying information on the enrollee, including name, enrollee Medicaid or member identification number, date of birth, sex and legal guardianship.
  • Must be legible and maintained in detail as to permit an external reviewer to follow the progression of care.
  • Contain a summary of significant surgical procedures, medical history, psychosocial history, past and current diagnosis or problems, allergies, current medications and untoward reactions to drugs
  • All entries must be dated and signed by the appropriate caregiver.
  • Must indicate the chief complaint or purpose of the visit; the objective findings of the practitioner; diagnosis or medical impression.
  • Must include vital signs and documented Weight and calculated BMI.
  • Must include documentation of counseling and referrals for recommended preventative care screenings based on enrollee age/gender as appropriate. (ie…Annual Dental Visit for children, PAP screening for women)
  • Must indicate studies ordered, for example: lab, x-ray, EKG, and referral reports. Test results and findings of diagnostic studies and consultation reports need to be reviewed by the physician and added to the record in a timely manner.
  • Must indicate therapies administered and prescribed.
  • Must include the name and profession of practitioner rendering services, for example: M.D, D.O., O.D., including signature or initials of practitioner.
  • Must include the disposition, recommendations, instructions to the patient, evidence of informed consent including risk and adverse outcome, whether there was follow up, and outcome of services.
  • Must contain a complete immunization history.
  • Must contain information related to enrollee’s use of tobacco, alcohol and drugs/substances.
  • Must contain summaries of all emergency services and care and hospital discharges (such as Discharge Summary) with the appropriate medically indicated follow-up.
  • Must contain a Health Risk Assessment Form when one is returned by the enrollee and sent to the provider.
  • Documentation of referral services (including Disease Management and/or Healthy Behaviors Program if applicable) and result of referral and/or consultation reports.
  • Documentation of all services provided, including but not necessarily limited to, family planning services, preventive services and services for the treatment of sexually transmitted diseases.
  • Reflect the primary language spoken by the enrollee and any translation needs of the enrollee.
  • Identify enrollees needing communication assistance in the delivery of healthcare services
  • For enrollees 18 years and older: Documentation that the enrollee was provided written information concerning the enrollee’s rights regarding advance directives (written instructions for living will or power of attorney) and whether or not the enrollee has executed advance directives. The execution or waiver of advance directives does not constitute a condition of treatment.
  • Must contain documentation of significant findings and medical advice given to enrollee or parent/guardian in person, by telephone, online or provider after-hours.
  • Record of enrollee treated elsewhere or transferred to another heath care provider are present.
  • Must include copies of any consent or attestation form used or the court order for prescribed psychotropic medication for a child under the age of thirteen (13)
  • Behavioral health records must include – for each services provided, clear identification as to:
    • The physician or other service provider
    • The date of service
    • The units of services provided AND
    • The type of service provided.