why providers need to maintain medical record and what are the standard?

Medical Records System

HMO providers must maintain a medical records system that is consistent with professional standards and that:

Permits prompt retrieval of information and provides legible and timely information, accurately documented, and readily available to members and/or appropriate or authorized health care practitioners.

Protects the confidentiality of patient records. There are occasions when Health Options may request to review and/or obtain copies of medical records from physicians to review quality of care, medical necessity, appropriateness of service, and/or clarification of treatment. The member’s enrollment application includes an authorization for the release of information that allows Health Options to obtain the medical records of the member and/or eligible spouse and dependents

Records in the medical record a summary of significant surgical procedures, past and current diagnoses or problems, allergies, and untoward reactions to drugs and current medications.

Identifies the patient by name, identification number, date of birth, and sex.

Indicates in the medical record for each visit the following information as appropriate: date; chief complaint or purpose of visit; objective findings of practitioner; diagnosis or medical impression; studies ordered (e.g., lab, X-ray, EKG, and referral reports); therapies administered and prescribed; name and profession of practitioner rendering services (e.g., M.D., D.O., D.C., D.P.M., R.N., O.D.) including signature or initials of practitioner; disposition, recommendations, instructions to the patient and evidence of whether there was follow-up; and, outcome of services.

Health Options performs regular review of physicians’ office medical records through the Quality Management program. The criteria utilized for this review incorporates the Florida Administrative Code’s requirements for medical record documentation.

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