A medical record documents a member?s medical treatment, past and current
health status, and treatment plans for future health care. It?s an integral
component in the delivery of quality health care. Independence has established
standards for medical record reviews to facilitate communication, aid in
coordination and continuity of care, and promote efficient and effective
treatment.
Independence?s standards for medical record documentation are in addition to
the medical record standards applicable to the provider under their state
legislative agency and the requirements of the Health Insurance Portability and
Accountability Act (HIPAA). Independence regularly assesses compliance with
these standards and monitors the processes and procedures used by physician
offices to facilitate the delivery of continuous and coordinated medical care.
Performance goals have been established to assess the quality of medical record
keeping. Below is a summary of the standards.
Documentation
Each medical record must include the following:
- a complete problem list;
- a prominent documentation of medication allergies and adverse reactions (if
the member has no known allergies or history of adverse reactions, this should
be appropriately documented in the record);
- food and other allergies, such as shellfish or latex, which may affect
medical management;
- past medical and surgical history, including prenatal, birth, and childhood
illnesses for members ages 18 and younger;
- current medications;
- documentation of clinical findings and evaluation for each visit;
- diagnoses consistent with findings;
- treatment or action plans consistent with the diagnoses;
- preventive services and risk screening.
Confidentiality
Confidentiality of medical records must be maintained as follows:
- Records are stored securely.
- Only authorized personnel have access to records.
- Staff receive periodic training in member information confidentiality.
Organization
Medical records should be organized and kept as follows:
- Medical records are organized and stored in a manner that allows for easy
retrieval.
- Medical records are stored in a secure manner that allows access by
authorized personnel only.
The complete set of standards for maintaining appropriate medical records is
accessible on our website. It can also be found in the Provider Manual
for Participating Professional Providers, which is available in the Current
Publications section of Independence NaviNet? Plan Central.
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