QUEST Integration – Medical Records Standards

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

Medical Records

The following medical record standards must be followed by providers:

• Records are maintained in a detailed and comprehensive manner that conforms to good professional medical practice
• Records are maintained in a manner that permits effective professional and medical review and medical audit processes
• Records are maintained in a manner that facilitates an adequate system for follow-up treatment
• Records are legible, signed and dated
• Each page of the paper or electronic record includes the patient’s name or ID number
• Records contain patient demographic information, including age, sex, address, home and work telephone numbers, marital status and employment, if applicable
• Records contain information on any adverse drug reactions and/or food or other allergies, or the absence of known allergies, which are posted in a prominent area on the medical record
• All forms or notes have a notation regarding follow-up care, calls or visits, when indicated;
• All medical records contain the patient’s past medical history that is easily identified and includes serious accidents, hospitalizations, operations and illnesses. For children, past medical history including prenatal care and birth;
• All pediatric medical records include a completed immunization record or documentation that immunizations are up-to-date;
• All medical records include the provisional and confirmed diagnosis(es);
• All medical records contain medication information;
• All medical records contain information on the identification of current problems (i.e., significant illnesses, medical conditions and health maintenance concerns);
• All medical records contain information about consultations, referrals, and specialist reports;
• All medical records contain information about emergency care rendered with a discussion of requirements for physician follow-up;
• All medical records contain discharge summaries for:
  • all hospital admissions that occur while the member is enrolled; and
  • prior admissions as appropriate;
• All medical records for members eighteen (18) years of age or older include documentation as to whether or not the member has executed an advance directive, including an advance mental health care directive;
• All medical records shall contain written documentation of a rendered, ordered or prescribed service, including documentation of medical necessity; and
• All medical records shall contain documented patient visits, which includes, but is not limited to:
  • A history and physical exam;
  • Treatment plan, progress and changes in treatment plan;
  • Laboratory and other studies ordered, as appropriate;
  • Working diagnosis(es) consistent with findings;
  • Treatment, therapies, and other prescribed regimens;
  • Documentation concerning follow-up care, telephone calls or visits, when indicated;
  • Documentation reflecting that any unresolved concerns from previous visits are addressed in subsequent visits;
  • Documentation of any referrals and results thereof, including evidence that the ordering physician has reviewed consultation, lab, x-ray, and other diagnostic test results/reports filed in the medical records and evidence that consultations and significantly abnormal lab and imaging study results specifically note physician follow-up plans;
  • Hospitalizations and/or emergency department visits, if applicable; and
  • All other aspects of patient care, including ancillary services.

Retention of Medical Records

All records must be kept confidential and maintained according to standard medical practice (see Medical Records Standards).They must permit effective professional medical review and audit processes and allow for the tracking of follow-up treatments. Records must be maintained for a minimum of least ten years from the last entry in the records. For minors, records must be maintained while they are minors plus a minimum of ten years after the age of majority. During the period of record retention, the state and federal governments must be allowed full access to the records, to the extent allowed by law.

If a patient changes PCP or health plan, the medical records are to be transferred to the new PCP within seven (7) business days from receipt of the records request.

Revision History