Medical Records Standards

All Prestige Health Choice Providers must maintain Medical Records for each Enrollee in accordance with the standards as listed below:

1. The Enrollee’s identifying information, including name, identification number, and other information as appropriate must be on each page of the medical record;

2. Each record must be legible and maintained in detail;

3. A summary of significant surgical procedures, past and current diagnoses or problems, allergies, untoward
reactions to drugs and current medications must be maintained;

4. All entries must be dated and signed by the appropriate party;

5. All entries must indicate the chief complaint or purpose of the visit, the objective, diagnoses, medical findings or impression of the provider;

6. All entries must indicate studies ordered (e.g., laboratory, x-ray, EKG) and referral reports;

7. All entries must indicate therapies administered and prescribed;

8. All entries must include the name and profession of the provider rendering services (e.g., MD, DO, OD), including the signature or initials of the provider. All notes written by physician extenders (ARNPs or PAs) must be co-signed by the assigned PCP, indicating his/her review and approval of the care rendered.

9. All entries must include the disposition, recommendations, instructions to the Enrollee, evidence of whether
there was follow-up and outcome of services;

10. All records must contain an immunization history;

11. All records must contain information relating to the Enrollee’s use of tobacco products and alcohol/substance abuse;

12. All records must contain summaries of all Emergency Services and Care and Hospital discharges with appropriate medically indicated follow up;

13. Documentation of referral services must be in Enrollee’s Medical Records. This is to include but not necessarily be limited to, family planning services, preventive services and services for the treatment of sexually transmitted diseases;

14. All records must reflect the primary language spoken by the Enrollee and any interpretive needs of the Enrollee;

15. All records must identify Enrollees needing communication assistance in the delivery of health care services; and,

16. All records must contain documentation that the Enrollee was provided with written information concerning the Enrollee’s rights regarding Advance Directives (written instructions for living will or power of attorney) and whether or not the Enrollee has executed an Advance Directive. Providers can not, as a condition of treatment, require the Enrollee to execute or waive an Advance Directive.

Confidentiality of Medical Records

Providers will ensure the confidentiality of all medical records in accordance with 42 CFR, Part 431, Subpart F and relevant HIPAA requirements. The confidentiality of a minor’s consultation, examination, and treatment for a sexually transmissible disease must be maintained in accordance with s. 384.30(2), F.S.

GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;

assessment, clinical impression, or diagnosis;

plan for care; and

date and legible identity of the observer.

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The Procedure  and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

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