Medical Records Documentation Standards

Carelink
December 2010
Consistent, current and complete documentation in the medical record is an essential
component of quality patient care. The following elements reflect a set of commonly
accepted standards for medical record documentation.
1. Each page in the record contains the patients name or ID number.
2. Personal biographical data include the address, employer, home and work
telephone numbers and marital status.
3. All entries in the medical record contain the authors identification. Author
identification may be a handwritten signature, unique electronic identifier or
initials.
4. All entries are dated.
5. The record is legible to someone other than the writer.
6. Significant illnesses and medical conditions are indicated on the problem list.
7. Medication allergies and adverse reactions are prominently noted in the record. If
the patient has no known allergies or history of adverse reactions, this is
appropriately noted in the record.
8. Past medical history (for patients seen three or more times) is easily identified and
includes serious accidents, operations and illnesses. For children and adolescents
(18 years and younger), past medical history relates to prenatal care, birth,
operations and childhood illnesses.
9. For patients 12 years and older, there is appropriate notation concerning the use of
cigarettes, alcohol and substances (for patients seen three or more times, query
substance abuse history).
10. The history and physical examination identifies appropriate subjective and
objective information pertinent to the patients presenting complaints.
11. Laboratory and other studies are ordered, as appropriate.
12. Working diagnoses are consistent with findings.
13. Treatment plans are consistent with findings.

14. Encounter forms or notes have a notation, regarding follow-up care, calls or visits,
when indicated. The specific time of return is noted in weeks, months or as
needed.
15. Unresolved problems from previous office visits are addressed in subsequent
visits.
16. There is review for under- or over-utilization of consultants.
17. If a consultation is requested, there is a note from the consultant in the record.
18. Consultation, laboratory and imaging reports filed in the chart are initialed by the
practitioner who ordered them, to signify review. (Review and signature by
professionals other than the ordering practitioner do not meet this requirement.) If
the reports are presented electronically or by some other method, there is also
representation of review by the ordering practitioner. Consultation and abnormal
laboratory and imaging study results have an explicit notation in the record of
follow-up plans.
19. There is no evidence that the patient is placed at inappropriate risk by a diagnostic
or therapeutic procedure.
20. An immunization record (for children) is up to date or an appropriate history has
been made in the medical record (for adults).
21. There is evidence that preventive screening and services are offered in accordance
with the organizations practice guidelines.

Additional Requirements for Carelink Medicaid per the West Virginia Bureau of
Medical Services (BMS):
West Virginia Medicaid Medical Record Documentation Guidelines
These standards must address health record content and organization, including
specifications of basic information to be included in each health record that include at
least the following:
1. Patient identification information: patient's name or patient ID number on each page
or electronic file;
2. Personal/biographical data: age, sex, address, employer, home and work telephone
numbers, and martial status;
3. Entry date;
4. Provider identification;

5. Allergies: medication allergies and adverse reactions are prominently noted on the
record, absence of allergies (no known allergies-NKA) is noted in an easily
recognizable location;
6. Past medical history (for patients seen 3 or more times): serious accidents,
operations, illnesses, prenatal care and birth (for pediatric patients);
7. Immunizations: for pediatric records (ages 12 and under) there is a completed
immunization record or a notation that immunizations are up-to-date, and when
subsequent immunizations, if any, are required;
8. Diagnostic information;
9. Medication information;
10. Identification of current problems: significant illness, medical conditions and health
maintenance concerns are identified in the medical record;
11. Smoking/ETOH/substance abuse: notation concerning cigarette and alcohol use and
substance abuse is present (for patients 14 years and over and seen three or more
times);
12. Consultations, referral and specialist reports: notes from consultations, lab, and x-ray
reports with the ordering physicians initials or other documentation signifying
review, explicit notation in the record and follow-up plans for significantly abnormal
lab and imaging study results;
13. Emergency care;
14. Hospital discharge summaries: all hospital admissions which occur while the patient
is enrolled in the plan, and prior admissions as necessary;
15. Advance directives: documentation of whether or not the individual has executed an
advance directive; and
16. Patient visit data: documentation of individual encounters must provide adequate
evidence of, at a minimum:

History and physical examination, including appropriate subjective and objective

information is obtained for the presenting complaints;
Plan of treatment;
Diagnostic tests;
Therapies and other prescribed regimens;
Follow-up, including encounter forms with notations concerning follow-up care,
or visits; return times noted in weeks, months or PRN; and unresolved problems
from previous visits are addressed in subsequent visits;
Referrals and results thereof; and
All other aspects of patient care, including ancillary services.
17. Information needed to conduct utilization review as specified in 42 CFR 456.111
and 42 CFR 438.211.

Medical records shall be legible. The record is legible to someone other than the writer, and
any record judged illegible by one physician reviewer should be evaluated
by a second reviewer.
The health plan must have a process to assess and improve the content, legibility,
organization, and completeness of enrollee health records. Enrollee health records must be
available and accessible to the health plan and to appropriate state and federal authorities, or
their delegates, involved in assessing the quality of care or investigating enrollee grievances
or complaints.