A medical record documents a member?s medical treatment, past and current
health status, and treatment plans for future health care, while also being an
integral component in the delivery of quality health care. Because of this,
Independence established medical records standards to facilitate communication,
aid in coordination and continuity of care, and promote efficient and effective
treatment. Independence regularly assesses compliance with these standards and
monitors the processes and procedures physician offices use 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:
complete problem list;
prominent documentation of medication allergies and adverse reactions (if
the member has no known allergies or history of adverse reactions, this is
appropriately documented in the record);
food allergies, such as shellfish, which may affect medication
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/action plans consistent with the diagnoses;
preventive services/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 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. They can also be found in
the Provider Manual for Participating Professional Providers (Provider
Manual), which is available in the Current Publications section of
Independence NaviNet® Plan Central. A paper copy of the
Provider Manual can be ordered by submitting an online request or by calling the Provider Supply Line at
1-800-858-4728.
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independent company.