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.
