Medical Record Documentation Standard
The Quality Improvement Department requires network participants to maintain medical records in a manner that is accurate,
timely, well-organized, readily accessible and confidential. In addition, the QI Department periodically reviews medical records to
ensure that they comply with established guidelines. The QI Department may conduct record reviews in response to nonroutine events, such as members’ complaints and reports of quality of care issues.
KEY ADMINISTRATIVE DOCUMENTATION STANDARDS
Personal biographical data This is required identifying information
(Legal guardian, if required)
Advance Directives
Signed HIPAA information form
All records of members 18 years and older must contain documentation of
Advance Directives. Copy of Advance Directives, if applicable.
Signed HIPAA Privacy Statement
GENERAL MEDICAL COMPONENTS
ADULT PREVENTIVE COMPONENTS
• Allergies documented or NKA noted in file
• Complete medical history for new members
• Problem list
• Complete PE for new members
• High risk behaviors and anticipatory guidance.
• Medication list
• Medical history/past and present (including surgical)
• Chief complaint (Subjective)
• Past social history and family history
• Blood transfusion history
• Current medications
• Objective findings/VS/BMI
• Diagnosis or medical impression
• Therapies administered and prescribed
• The working diagnoses are consistent with findings
• Coordination of care and follow-up
• Adult Preventive Components
• Measurements/vital signs
• Screening:
- Cholesterol
- EKG
- Diabetes screening
- AAA screening
- Tuberculosis (TB)
- Osteoporosis screening/testing
- Vision and hearing
-
Pain Screening
-
Functional Assessment
Chlamydia test
Breast exam/mammography
Cervical cancer screening
Colorectal cancer screening
Skin cancer
HIV screening
Behavioral health screening
Alcohol screening/Misuse
Tobacco use screening
REQUIRED SCREENING COMPONENTS
• Diabetes Screening (as required)
• Pediatric and Adolescent Preventive Components (as required)
• Maternity Medical Components (as required)
• AIDS/HIV Component
• Safety Component