Committee for Quality Assurance (NCQA) and URAC guidelines on standards for medical record documentation, Horizon BCBSNJ requires participating physicians and other health care professionals to adhere to the following commonly accepted practices regarding medical record documentation. The items below are also used in our medical record audits:
• Medical Record Organization
Medical records will be organized and maintained in a systematic and consistent manner that allows easy retrieval.
• Medical Record Availability
The Practitioner has a process to make records available to covering practitioners and others, as needed. Practitioner
communicates to staff guidelines relative to the dispersal/retrieval of confidential patient medical records within and/or outside the office, such as in the case of a covering practitioner requesting medical records. • Medical Record Confidentiality
Access to medical records is limited to appropriate office staff:
- All medical records are stored out of reach and view of unauthorized persons.
- All electronic medical records are
maintained in a system that is secure and not accessible by unauthorized persons. - Staff receives periodic training in member
information confidentiality. • Dated Entries
Entries and updates to a medical record are dated with the applicable month, day and year.
• Author Identification
Entries are initialed or signed by the author. Author identification may be a handwritten signature, unique electronic identifier, initials or any other unique identifier system the Practitioner chooses.
• Page Identification
Patient name or unique identifier is found on each page in the medical record.
• Personal/Biographical Data
The medical record will contain patient personal/biographical information such as: – Patient’s insurer.
– Patient’s home address.
– Patient’s home, work and/or cell phone number.
– Emergency contact name and telephone number.
• Legible Entries
Entries and updates are legible to a reader other than the author.
• Medication Allergies and/or Adverse
Reactions
Information on allergies and adverse reactions (or a notation that the patient has no known allergies or history of adverse reactions) are prominently displayed in the medical record.
• Prescribed Medications
Maintain a list of prescribed medications which include dosages and dates of initial or refill prescriptions.
• Updated Problem List
A dated problem list summarizing a patient’s significant illnesses, as well as medical and psychological conditions, will be maintained. • Presenting Complaints/Physical
Examinations
Presenting complaints, physical
examinations, diagnoses, treatment plans and possible risk factors for the patient, relevant to the particular treatment, are noted.
• Follow-up Care
Entries are recorded stipulating when the patient should return for follow-up care. • Laboratory Results
Laboratory results are reviewed and initialed by the Practitioner.
• Tobacco, Alcohol and Substance Abuse For patients age 14 and older, there are appropriate entries made concerning the use of cigarettes and alcohol, and substance abuse (including anticipatory guidance and health education).
• Medical History
Past medical history, including serious accidents, operations and illnesses are prominently documented for patients who have had three or more visits.
• Immunization Records
Childhood immunization records are present for children under the age of 14.
• Growth Chart
Create and maintain a growth chart for pediatric patients.
• Advance Directives
Information on Advance Directives is noted in the medical record for all Medicare Advantage members, including a completed copy of the directive or member’s decision not to execute.
• Provider List
Physicians and other health care
professionals involved in the patient’s care can be easily identified in the patient’s chart. • Preventive Services/Risk Screening
Each patient record includes documentation that age-appropriate preventive services were ordered and performed or that the physician discussed age-appropriate
preventive services with the patient and the patient chose to defer or refuse them. Physicians should document that a patient sought preventive services from another physician (e.g., Ob/Gyn, cardiologist, etc.) and include results of such services as reported by the patient.
Medical Record Documentation Compliance Audits
The Quality Management staff conducts an annual Medical Record Documentation Compliance Audit to assess compliance with our medical record documentation standards and as an annual requirement for health plan accreditation by the NCQA.
We randomly select 20 Primary Care Physician offices to participate. Offices must have a panel size of 250 or more patients and must have been participating in the Horizon Managed Care Network for a minimum of 24 months. The medical records of five Horizon BCBSNJ members from each office, also selected at random, are reviewed for their compliance with our Medical Record Documentation Standards as appropriate for the member’s age and plan in which he or she is enrolled.
Actions are taken to improve medical record keeping practices of those offices that do not meet a performance threshold of 80 percent. Procedures to improve content, organization and completeness of member records may include on-site counseling, physician
communications, best practice materials, etc. Audit results identifiable to a particular practice are only released to that practice. Overall audit results (excluding any
identifiable information regarding physicians or members) and specific strategies for medical record documentation improvement are communicated in Blue Review.
Please note that you may not charge Horizon BCBSNJ for medical records when they are requested for medical review, claim review or as part of a medical record audit for a site visit.
Medicare Advantage Medical Record Retention
Physicians and other health care professionals are required to maintain medical records for a minimum of 10 years for all Medicare
Advantage members.