Medical record keeping standards

Medical records facilitate the delivery of quality health care through the documentation of past and current health status, diagnoses, and treatment plans. As such, AmeriHealth has established standards for medical records to promote efficient and effective treatment by facilitating communication and the coordination and continuity of care.

The AmeriHealth New Jersey medical record standards policy is reviewed annually. The policy addresses confidentiality of medical records, medical records documentation standards, an organized medical record keeping system, standards for availability of medical records, maintenance and auditing of medical records, and performance goals to assess the quality of medical record keeping. AmeriHealth New Jersey’s standards for medical record documentation are in addition to state and federal laws, including the requirements of the Health Insurance Portability and Accountability Act (HIPAA).

Each medical record should comply with the following standards:

Medical record content

  • Significant illnesses and medical conditions indicated on the problem list
  • Documentation of medications — current and updated
  • Prominent documentation of medication allergies and adverse reactions; if there are no known allergies or history of adverse reactions, this is appropriately noted
  • Food and other allergies, such as shellfish or latex, which may affect medical management
  • Past medical history (for patients seen three or more times), including serious accidents, operations, and illnesses; for children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses
  • For patients 12 years and older, appropriate notations concerning use of cigarettes, alcohol, and substance abuse (for patients seen three or more times, query substance abuse history)
  • History and physical documentation includes subjective and objective information for presenting complaints
  • Working diagnoses consistent with findings
  • Treatment or action plans consistent with diagnoses
  • Unresolved problems from previous office visits are addressed in subsequent visits
  • Documentation of clinical evaluation and findings for each visit
  • Appropriate notations regarding the utilization of consultants
  • No evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure
  • Documentation of preventive services and risk screening
  • Immunization record for children is up to date or an appropriate history is made for adults

Medical record organization

  • Each page in the record contains the patient’s name or ID number
  • Personal/biographical data include address, employer, home and work telephone numbers, and marital status
  • All entries contain the author’s identification; author identification may be a handwritten signature, a unique electronic identifier, or initials
  • All entries are dated
  • The record is legible to someone other than the writer

Information field in medical records

  • All services provided directly by a primary care practitioner
  • All ancillary services and diagnostic tests ordered by a practitioner
  • All diagnostic and therapeutic services for which a member was referred by a practitioner (such as home health nursing reports, specialty physician reports, hospital discharge reports, and physical therapy reports)
  • Laboratory and other studies are ordered, as appropriate
  • Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls, or visits; the specific time of return is noted in weeks, months, or as needed
  • If a consultation is requested, there is a note from the consultant in the record
  • Specialty physician, other consultation, laboratory, and imaging reports filed in the chart are initialed by the practitioner who ordered them to signify review; review and signature by professionals other than the ordering practitioner do not meet this requirement
  • If the reports are presented electronically, or by some other method, there is also representation of review by the ordering practitioner
  • Consultation: abnormal lab and imaging study results have an explicit notation in the record of follow-up plans
  • The existence of an Advance Directive is prominently documented in each adult (older than 18 years of age) member’s medical record; information as to whether the Advance Directive has been executed is also noted

Retrieving Medical Records

  • Medical records are to be made available to the Plan as defined in the Professional Provider Agreement

Confidentiality of medical records

  • Protected Health Information (PHI) is protected against unauthorized or inadvertent disclosure
  • At a minimum, medical records must be maintained for at least ten years, or age of majority plus six years, whichever is longer
  • Records are stored securely
  • Only authorized personnel have access to records
  • Staff receive periodic training in member information confidentiality

Maintenance of records and audits

Providers must maintain all medical and other records in accordance with the terms of their Professional Provider Agreement and the Provider Manual for Participating Professional Providers. When requested by AmeriHealth New Jersey or its designated representatives, or designated representatives of local, state, or federal regulatory agencies, the provider shall produce copies of any such records and will permit access to the original medical records for comparison purposes within the requested time frames and, if requested, shall submit to examination under oath regarding the same. If a provider fails or refuses to produce copies and/or permit access to the original medical records within 30 days as requested, AmeriHealth New Jersey reserves the right to require Selective Medical Review before claims are processed for payment to verify that claims submissions are eligible for coverage under the benefits plan.