Standards for medical record documentation: Medical record review

July 9, 2020

Medical records facilitate the delivery of quality health care through the documentation of past and current health status, diagnoses, and treatment plans. Independence has established standards for medical records to promote efficient and effective treatment by facilitating communication, and the coordination and continuity of care. Independence’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). Standards focus on documentation, confidentiality, storage, and organization. They are summarized below.

Documentation

Each medical record must include the following:

  • 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;
  • for adults, past medical history, including serious accidents, operations, and illnesses;
  • for children and adolescents, 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;
  • history and physical documentation include 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 addressed in subsequent visits;
  • documentation of clinical evaluation and findings for each visit;
  • appropriate notations regarding the use of consultants;
  • no evidence that the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure;
  • documentation of preventive screening/risk screening;
  • immunization record for children is up to date or an appropriate history in the medical record for adults. 

Confidentiality and storage

Medical records and protected health information must be safeguarded against loss or destruction and maintained according to state requirements. At a minimum:

  • Medical records are maintained, beginning on the date of the last medical service, for at least 11 years, or age of majority plus six years, whichever is longer.
  • Medical records are stored securely in a way that allows access by authorized personnel only.
  • Staff receive periodic training in member information confidentiality. 

Organization

Medical records must be organized as follows:

  • Each page in the record contains at least two patient identifiers (name, date of birth, etc.) 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.
  • All entries are legible to someone other than the writer. 

Independence annually assesses compliance with these standards through medical record review to ensure the delivery of continuous and coordinated medical care. Practice-specific or plan-wide improvement activities may be requested or initiated if Independence medical record standards are not met.

Learn more

The complete set of standards for maintaining medical records is available on our website. Information can also be found in the Provider Manual for Participating Professional Providers, which is available through the NaviNet® web portal (NaviNet Open). 

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