A medical record documents a member?s medical treatment, past and current health status, and treatment plans for future health care. It?s an integral component in the delivery of quality health care. Independence has established standards for medical record reviews to facilitate communication, aid in coordination and continuity of care, and promote efficient and effective treatment.

Independence?s standards for medical record documentation are in addition to the medical record standards applicable to the provider under their state legislative agency and the requirements of the Health Insurance Portability and Accountability Act (HIPAA). Independence regularly assesses compliance with these standards and monitors the processes and procedures used by physician offices to facilitate the delivery of continuous and coordinated medical care. Performance goals have been established to assess the quality of medical record keeping. Below is a summary of the standards.

Documentation

Each medical record must include the following:

• a complete problem list;
• a prominent documentation of medication allergies and adverse reactions (if the member has no known allergies or history of adverse reactions, this should be appropriately documented in the record);
• food and other allergies, such as shellfish or latex, which may affect medical management;
• past medical and surgical history, including prenatal, birth, and childhood illnesses for members ages 18 and younger;
• current medications;
• documentation of clinical findings and evaluation for each visit;
• diagnoses consistent with findings;
• treatment or action plans consistent with the diagnoses;
• preventive services and risk screening.

Confidentiality

Confidentiality of medical records must be maintained as follows:

• Records are stored securely.
• Only authorized personnel have access to records.
• Staff receive periodic training in member information confidentiality.

Organization

Medical records should be organized and kept as follows:

• Medical records are organized and stored in a manner that allows for easy retrieval.
• Medical records are stored in a secure manner that allows access by authorized personnel only.

The complete set of standards for maintaining appropriate medical records is accessible on our website. It can also be found in the Provider Manual for Participating Professional Providers, which is available in the Current Publications section of Independence NaviNet^? Plan Central.

NaviNet is a registered trademark of NaviNet, Inc., an independent company.