Medical records facilitate the delivery of quality health care through the
documentation of past and current health status, diagnoses, and treatment
plans. Independence has established standards for medical records to promote
efficient and effective treatment by facilitating communication, and the
coordination and continuity of care.
Independence’s standards for medical record documentation are in
addition to state and federal laws, including the requirements of the Health
Insurance Portability and Accountability Act (HIPAA). Standards focus on
documentation, confidentiality, storage, and organization. They are summarized
below.
Documentation
Each medical record must include the following:
- significant illnesses and medical conditions indicated on the problem
list;
- documentation of medications – current and updated;
- prominent documentation of medication allergies and adverse reactions; if
there are no known allergies or history of adverse reactions, this is
appropriately noted;
- food and other allergies, such as shellfish or latex, which may affect
medical management;
- for adults, past medical history, including serious accidents, operations,
and illnesses;
- for children and adolescents, past medical history relates to prenatal
care, birth, operations, and childhood illnesses;
- for patients 12 years and older, appropriate notations concerning use of
cigarettes, alcohol, and substance abuse;
- history and physical documentation include subjective and objective
information for presenting complaints;
- working diagnoses consistent with findings;
- treatment or action plans consistent with diagnoses;
- unresolved problems from previous office visits addressed in subsequent
visits;
- documentation of clinical evaluation and findings for each visit;
- appropriate notations regarding the use of consultants;
- no evidence that the patient is placed at inappropriate risk by a
diagnostic or therapeutic procedure;
- documentation of preventive screening/risk screening;
- immunization record for children is up to date or an appropriate history in
the medical record for adults.
Confidentiality and storage
Medical records and protected health information must be protected against
unauthorized or inadvertent disclosure in the following ways:
- Medical records must be maintained for at least ten years, or age of
majority plus six years, whichever is longer.
- Records are stored securely.
- Only authorized personnel have access to records.
- Staff receive periodic training in member information confidentiality.
Organization
Medical records must be legible and organized as follows:
- Each page in the record contains at least two patient identifiers (name,
date of birth, etc.) or ID number.
- Personal/biographical data include address, employer, home and work
telephone numbers, and marital status.
- All entries contain the author’s identification; author
identification may be a handwritten signature, a unique electronic identifier,
or initials.
- All entries are dated.
Independence annually assesses compliance with these standards through
medical record review to ensure the delivery of continuous and coordinated
medical care. Practice-specific or plan-wide improvement activities may be
requested or initiated if Independence medical record standards are not met.
Learn more
The complete set of standards for maintaining medical records is accessible
online. Information can also be found in the
Provider Manual for Participating Professional Providers, which is
available through the NaviNet® web portal (NaviNet
Open).
NaviNet® is a registered trademark of
NantHealth, an independent company.