A medical record documents a member's medical treatment, past and current
health status, and treatment plans
for future health care, while also being an integral component in the delivery
of quality health care. Because of this,
Independence established medical records standards to facilitate communication,
aid in coordination and continuity
of care, and promote efficient and effective treatment. Independence regularly
assesses compliance with these
standards and monitors the processes and procedures physician offices use 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:
- complete problem list;
- prominent documentation of medication
allergies and adverse reactions (if the
member has no known allergies or history
of adverse reactions, this is appropriately
documented in the record);
- food allergies, such as shellfish, which may
affect medication 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/action plans consistent with the diagnoses;
- preventive services/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 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. They can also be found in the
Provider Manual
for Participating Professional Providers (Provider Manual), which is
available in the Current Publications section of Independence
NaviNet
® Plan Central. A paper copy of the
Provider
Manual can be ordered by submitting an
online request
or by calling the Provider Supply Line at
1-800-858-4728.
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independent company.