Medical Records

Participating physicians have agreed to establish and maintain medical records for HMSA members in accordance with generally accepted medical practices, plan documents and applicable federal and state regulations.

Access to Records

Participating physicians will allow HMSA medical directors or other medical professionals designated by HMSA access to HMSA member records for the following purposes:

• Utilization review
• Quality assurance
• Credentialing and recredentialing
• Claims payment verification
• Fraud and abuse investigations

Medical professionals designated by HMSA will be allowed access to HMSA member records in the participating physician’s office at a mutually agreeable time within five working days of HMSA’s request. Physicians also may be asked to transmit medical records to HMSA via fax or other electronic means, or by mailing in photocopies.

Confidentiality

HMSA will take all necessary precautions to maintain patient confidentiality and prevent the unauthorized disclosure of medical records. Access to medical records is only granted to certain HMSA employees on an as-needed basis, and all HMSA employees, as a condition of their employment, must sign statements pledging to preserve the confidentiality of medical information. For more information about HMSA’s privacy practices, see Privacy

Quality Assurance Record Reviews

HMSA conducts routine medical record reviews as part of its Quality Improvement Program (see Quality Improvement Program) The reviews are conducted to assess a practitioner’s performance in providing quality healthcare services to HMSA members.

Practitioners will receive written results within two weeks from the date of the evaluation. The goal is an 80 percent or better aggregate score. A reevaluation is scheduled if a score of less than 80 percent is found.

In the case of a failed review, an HMSA Medical Director or a designee will review the results before the report is sent to the practitioner. The letter may include corrective action measures with recommendations and a reevaluation schedule.

Criteria

The criteria for member medical records are critical standards of care management that indicate the level of care being provided. The guidelines for the medical record review address four major categories:

• General patient information and medical history
• Appropriateness of treatment
• Continuity of care
• Confidentiality compliance

General patient information and medical history criteria

An HMSA practitioner must maintain his or her medical records in a manner that is current, detailed, organized and inclusive of all aspects of care.

The following are “critical areas” that need to be included in the medical record and should be easy to access:

• Problem list of current and significant medical conditions
• List of medications, including allergies and adverse reaction to medication. Also include documentation if there are no known allergies.
• Past medical history, including serious accidents, operations, hospitalizations (including discharge summaries), prior admissions, illnesses and all other aspects of patient care including patient services. For children and adolescents (age 18 and younger), include a past medical history as it relates to prenatal care, birth, immunizations, operations and childhood illnesses.
• Working diagnosis, findings, and treatment plans that are consistent with each other

In addition to the above critical areas, the medical record should also include:

• The patient’s name or ID number on every page
• Personal/biographical data, such as address, employer, home and work telephone numbers and marital status
• For those patients age 65 and older (or age 18 and older for QUEST), documentation that the patient has executed an advance health care directive. (See Advance Directives - Senior Plans)
• Author identification/signature and date the entry was made on all practitioner/staff entries
• Notations regarding substance abuse and the use of cigarettes and alcohol for patients seen three or more times and who are age 12 or older
• A note or consultation report from any consultant indicating his or her findings
• Consultations, labs and imaging reports are initialed by the practitioner or some other method is used to signify the practitioner’s review.
• Consultations and abnormal labs or imaging studies include an explicit notation of planned follow-up care
• A current and complete immunization record for children. Records for adults should include an appropriate immunization history.

Note: The medical record should be orderly and legible, so that someone other than the writer can access the information and easily read the contents.

Appropriateness of care

• The history and physical documents in a patient’s medical record should contain appropriate subjective and objective information about the patient’s presenting complaints.
• The labs and other studies ordered should be appropriate to the patient’s presenting complaints.
• The determined diagnosis should be logically based on the presenting findings or the results of any diagnostic tests.
• The practitioner’s plan for treatment/action should be appropriate for the patient’s diagnosis.
• Encounter forms or notes should show, when indicated, needed follow-up care, calls or visits. The specific time of return should be noted in weeks, months, or as needed.
• Unresolved problems from previous office visits should be addressed in subsequent visits. (Continuous care is demonstrated — not episodic.)
• Review will be made for under- and over-utilization of consultants.
• There should be no evidence that the patient was placed at inappropriate risk by a diagnostic or therapeutic procedure.
• There should be evidence that preventive screening and services were offered in accordance with HMSA’s Clinical Practice Guidelines.

Continuity of care criteria

To preserve continuity of care for HMSA members, PCPs should document all referrals to specialists in the member’s medical record. Practitioners should sign and date all referred diagnostic reports and/or communication from specialists. All Emergency Room follow-up visits by the patient to his or her own practitioner should include notes about the follow-up care provided.

Confidentiality compliance criteria

All HMSA practitioners should uphold policies and procedures pertaining to confidentiality of specified patient information in medical records. Policies and procedures that are reviewed as part of a health center’s quality improvement activities include:

• Medical records should be in closed cabinets or in a room away from public access areas.
• Each patient should have his or her own medical record.
• The practitioner’s office should have a written policy or form that requires obtaining the written permission from the patient prior to releasing his or her records outside the office.
• The practitioner’s office should have a written policy or form stating that all the information contained in the patient’s records is confidential and will not be discussed or disclosed outside the office without the patient’s permission.
• The practitioner’s office should have an established system for organizing, filing and tracking of information in the medical records (does not apply to independent practice associations [IPAs]).

Guidelines for Behavioral Health Treatment Record Keeping

• Each page (electronic or paper) contains the member’s name or identification number.
• Each record includes the member’s address, employer or school, home and work telephone numbers including emergency contacts, marital or legal status, appropriate consent forms and guardianship information, if relevant.
• All entries in the treatment record are dated and included the responsible clinician’s name, professional degree, and relevant identification number, if applicable. The length of the visit/session is recorded, including visit/session start and stop times.
• The record, when paper based is legible to someone other than the writer.
• Medication allergies, adverse reactions and relevant medical conditions are clearly documented and dated. If the member has no known allergies, history of adverse reactions or relevant medical conditions, this is prominently noted.
• Presenting problems, along with relevant psychological and social conditions affecting the member’s medical and psychiatric status and the results of a mental status exam, are documented.
• Special status situations, when present, such as imminent risk of harm, suicidal ideation or elopement potential, are prominently noted, documented, and revised in compliance with written protocols.
• Each record indicates what medications have been prescribed, the dosages of each and the dates of initial prescription or refills.
• A medical and psychiatric history is documented, including previous treatment dates, practitioner identification, therapeutic interventions and responses, sources of clinical data, and relevant family information.
• For children and adolescents, past medical and psychiatric history includes prenatal and perinatal events (when available), along with a developmental history (physical, psychological, social, intellectual and academic).
• For members 12 and older, documentation includes past and present use of cigarettes and alcohol as well as illicit, prescribed, and over-the-counter drugs.
• A DSM (or the most current version of the DSM) diagnosis is documented, consistent with the presenting problems, history, mental status examination, and/or other assessment data.
• Treatment plans are consistent with diagnosis, have both objective, measureable goals and estimated timeframes for goal attainment or problem resolution, and include a preliminary discharge plan, if applicable.
• Treatment plans are updated as needed to reflect changes/progress of the member.
• Continuity and coordination of care activities between the primary clinician, consultants, ancillary providers, and health care institutions are documented as appropriate.
• Informed consent for medication and the member’s understanding of the treatment plan are documented.
• Additional consents are included when applicable (e.g., alcohol and drug information releases).
• Progress notes describe the member’s strengths and limitations in achieving treatment plan goals and objectives and reflect treatment interventions that are consistent with those goals and objectives.
• Progress notes include psychotherapy techniques, benefits and treatment goals
• Progress notes contain sufficient documentation of the service, care, and treatment which supports medical necessity
• Documented interventions include continuity and coordination of care activities, as appropriate.
• Dates of follow-up appointments or, as applicable, discharge plans are noted.

Revision History