Standard for Medical records - General Guidelines

Medical record standards

Medical records will contain all information necessary and appropriate for quality improvement activities and to support claims for services submitted by you.

In providing care for UnitedHealthcare members, we expect that you have signed, written policies to address the following (critical elements appear in bold text in this section):

1. Maintain a single, permanent medical record that is current, detailed, organized and comprehensive for each
member and is available at each visit.

2. Protect member records, whether in paper or electronic form, against loss, destruction, tampering or
unauthorized use. For electronic medical records, you must establish security safeguards in order to prevent
unauthorized access or alteration of records without leaving an audit trail to identify the breach. Such safeguards must be programmed so that they cannot be overridden or turned off.

3. Maintain medical records in a confidential manner and provide periodic training to office staff
regarding confidentiality processes. Records storage must allow for easy retrieval, be secure and allow
access only by authorized personnel.

4. Maintain a mechanism for monitoring and handling missed appointments.

5. Demonstrate the office does not discriminate in the delivery of health care.

General documentation guidelines

We also expect you to follow these commonly accepted guidelines for medical record information and documentation:

• Date all entries, and identify the author and their credentials when applicable. For records generated by word processing software or electronic medical record software, the documentation should include all authors and their credentials. It should be apparent from the documentation which individual performed a given service.

• Clearly label or document subsequent changes to a medical record entry by including the author of the change and date of change. The provider must also maintain a copy of the original entry.
• Generate documentation at the time of service or shortly thereafter.

• Make entries legible.

• Cite medical conditions and significant illnesses on a problem list and document clinical findings and
evaluation for each visit.
• Documentation that is not reasonable and necessary for the diagnosis or treatment of an injury or illness or to
improve the function of a malformed body member (over documentation) should not be considered when selecting the appropriate level of an E&M service. Only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate E&M level.
• Give prominence to notes on medication allergies and adverse reactions. Also, note if the member has
no known allergies or adverse reactions.
• Make it easy to identify the medical history, and include chronic illnesses, accidents and operations.
• For medication records, include name of medication and dosages. Also, list over the counter drugs
taken by the member.
• Records reflect all services provided, ancillary services/tests ordered, and all diagnostic/therapeutic services referred by the physician/health care professional.
• Clearly label any documentation generated at a previous visit as previously obtained, if it is included in the
current record.

Document these important items:
• Tobacco habits, including advice to quit, alcohol use and substance abuse for members age eleven (11) and older
• Immunization record
• Family and social history
• Preventive screenings/services and risk screenings
• Screening for depression and evidence of coordination with behavioral health providers
• Blood pressure, height and weight, body mass index

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