Chapter 29: Medical Record Guidelines

This chapter contains policies for maintaining member medical records, including medical record standards and contractual requirements regarding retention and disclosure of information. These guidelines are used to perform clinical audits in conjunction with ongoing quality assurance activities.

EmblemHealth requires its providers to maintain accurate medical records. The primary purpose of the record is to document the course of the member's health, and illness and treatments. The record also serves as a mode of communication between physicians and other professionals participating in the member’s care, as well as between settings. The entire medical record of an active member must remain in the primary care physician's office or within the facility in which the member was treated, and must be consistent with all relevant local, state and federal laws, rules, and regulations.. EmblemHealth may request a copy of, or make an on-site visit to review, your medical records for internal and regulatory chart audits.

Medical Record Content and Format

Have the author’s identification: a handwritten signature, unique electronic identifier, or initials.
Have a date of service.
Is complete and legible to someone other than the writer.

Primary Care Physician (PCP) – Coordination of Care
The record verifies that the PCP coordinates and manages the member's care. In cases when a member’s benefit plan does not require a PCP assignment, the primary physician managing the member’s care would coordinate that care. Each member should have a unique medical record that contains at least the following information:

Name on each page in the medical record
EmblemHealth ID number on each page in the medical record
Date of birth
Address and phone number
Employer's name, address, and phone number
Marital status
Benefit plan participation and copayment (if applicable)
Name of the primary care physician (PCP)
List of allergies and/or adverse reactions, or "No Known Allergies" (NKA)
Patient’s self-reported race, ethnicity, and preferred language

Comprehensive baseline history and physical (see details below)
Diagnostic test results
Consult reports
Progress notes
Medication records, including medications, dosage, frequency, dates of initial and/or refill prescriptions, over-the-counter medications, supplements, etc.
Problem list, including but not limited to past medical history, chronic or significant ongoing acute medical conditions, significant surgical conditions, and significant behavioral health conditions.
Allergy and/or adverse reactions to drugs documentation. Note if no known allergies and/or adverse reactions.
Telephone/communication log
Immunization records
Preventive health screening records
Inpatient/ER discharge summary reports, if applicable*
Operative reports, if applicable

* The PCP must also clearly document any follow-up on the member's ER visit and/or hospitalization, whether an office visit, written correspondence, or telephone conversation.

The comprehensive baseline history and physical must include a review of:

Subjective and objective complaints/problems
Family history
Social history (i.e., occupation, education, living situation, risk behaviors)
Significant accidents, surgeries, illnesses, and mental health issues
Complete and comprehensive review of systems (including patient's presenting complaint, as applicable)
Social determinants of health
Cultural needs including family, social, religious, literacy
Cognitive abilities
Psychosocial emotional health and prior treatment
Reports from other physicians and treatment including vision, hearing, information from specialists, facilities
Family support
Prenatal care and birth information (baseline, 18 years and younger only) in cases where the member has both a PCP and an OB/GYN, they must coordinate to ensure there is a centralized medical record for the provision of prenatal care and all other services

Periodic reviews of history and physicals should be repeated in accordance with age-appropriate preventive care guidelines.

Within the record (electronic or paper), reports of similar type (i.e., progress notes, laboratory reports) should be filed together in chronological or reverse chronological order permitting easy retrieval of information and initialed by the physician to indicate they have been read. Each progress note filed should be legibly written or typed, signed and dated by the author, and contain at least the following items:

The reason for visit as stated by the member
The duration of the problem
Findings on physical examination
Laboratory and x-ray results, if any
Diagnosis or assessment of the member's condition
Therapeutic or preventive services prescribed, if any
Dosage, duration, and side-effect information of any prescription given, with medication allergies and adverse reactions noted prominently (updated during a physical, when a prescription is written, or annually, whichever comes soonest)
Follow-up plan (including self-care training and actions) or that no follow-up is required
Time to next visit and other follow-up appointments

Reports generated in response to a request for a test or consultation must be filed immediately in the medical record with the member's name, ID number, and date of birth on each document page.

Test results should be reported to the member within a reasonable time after the physician receives, reviews, and files with a progress note indicating when the member is notified, by whom, and the next steps in the treatment plan.

Provider Signature Attestation
The Centers for Medicare & Medicaid Services (CMS) requires each date of service in a member's medical record to be accompanied by a legible provider signature and credentials. Some examples of appropriate credentials are MD, DO, and PhD. For your medical records to be deemed compliant, you must authenticate each note for which services are provided. Acceptable physician authentication includes handwritten and electronic signatures or signature stamps. Please review the tables that follow for examples of acceptable and unacceptable signatures and credentials.

ACCEPTABLE PHYSICIAN SIGNATURES AND CREDENTIALS
Signature Type	Acceptable
Handwritten signature or initials, including credentials	Mary C. Smith, MD or John J. Smith, DO or, for initialing – MCS, MD or JJS, DO
Signature stamp, including credentials	Must comply with state regulations for signature stamp authorization
Electronic signature, including credentials	Must be password protected and used exclusively by the individual physician

Approved by
Signed by
Electronically signed by

UNNACCEPTABLE PHYSICIAN SIGNATURES AND CREDENTIALS WITH CORRECTIVES
Signature Type	Acceptable
Provider signature without credentials	Name is linked to provider credentials or name on physician stationary
Typed name	Name is authenticated by the provider
Signed by a non-physician or a non-physician extender (e.g., medical student)	Signature is co-signed by responsible physician