Medical record
standards
Medical records will contain all information necessary and appropriate for
quality improvement activities and to support claims for services
submitted by you.
In providing care for UnitedHealthcare members, we expect that you have signed,
written policies to address the following (critical elements appear in
bold text in this section):
1. Maintain a single, permanent medical record that is current, detailed,
organized and comprehensive for each member and is available at each visit.
2. Protect member records, whether in paper or electronic form, against loss,
destruction, tampering or
unauthorized use. For electronic medical records, you must establish security
safeguards in order to prevent unauthorized access or alteration of records without leaving an audit trail to
identify the breach. Such safeguards must be programmed so that they
cannot be overridden or turned off.
3. Maintain medical records in a confidential manner and provide periodic
training to office staff
regarding confidentiality processes. Records storage must allow for easy
retrieval, be secure and allow
access only by authorized personnel.
4. Maintain a mechanism for monitoring and handling missed appointments.
5. Demonstrate the office does not discriminate in the delivery of health care.
General documentation guidelines
We also expect you to follow these commonly accepted guidelines for medical
record information and documentation:
• Date all entries, and identify the author and their credentials when
applicable. For records generated by word processing software or
electronic medical record software, the documentation should include all
authors and their credentials. It should be apparent from the
documentation which individual performed a given service.
• Clearly label or document subsequent changes to a medical record entry by
including the author of the change and date of change. The provider must
also maintain a copy of the original entry.
• Generate documentation at the time of service or shortly thereafter.
• Make entries legible.
• Cite medical conditions and significant illnesses on a problem list and
document clinical findings and
evaluation for each visit.
• Documentation that is not reasonable and necessary for the diagnosis or
treatment of an injury or illness or to improve the function of a malformed body member (over documentation) should not
be considered when selecting the appropriate level of an E&M service.
Only the medically reasonable and necessary services for the condition
of the particular patient at the time of the encounter as documented can
be considered when selecting the appropriate E&M level.
• Give prominence to notes on medication allergies and adverse reactions. Also,
note if the member has no known allergies or adverse reactions.
• Make it easy to identify the medical history, and include chronic illnesses,
accidents and operations.
• For medication records, include name of medication and dosages. Also, list
over the counter drugs
taken by the member.
• Records reflect all services provided, ancillary services/tests ordered, and
all diagnostic/therapeutic services referred by the physician/health care
professional.
• Clearly label any documentation generated at a previous visit as previously
obtained, if it is included in the current record.
Document these important items:
• Tobacco habits, including advice to quit, alcohol use and substance abuse for
members age eleven (11) and older
• Immunization record
• Family and social history
• Preventive screenings/services and risk screenings
• Screening for depression and evidence of coordination with behavioral health
providers
• Blood pressure, height and weight, body mass index
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