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PAP107

Medical Records Standards


Provider Administrative Policy

Section
Information
Policy Date
May 2008
Status/Date
Revised/February 2013
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Medical Records Standards

Providers are required to maintain a medical record-keeping system that conforms to professional medical practice, facilities audits and claim reviews, and ensures appropriate follow-up treatment and coordination of care. All medical records should be kept for at least 10 years after the date of medical services for which claims have been submitted. The minimum standards are as follows:

  • Every page in the record contains the member’s name and ID number
  • The record includes the member’s address, employer, home and work telephone numbers and marital status
  • The record is legible to a physician reviewer
  • Significant medical conditions are indicated on the problem list
  • The record includes a health maintenance plan
  • Medication allergies and adverse reactions are noted prominently
  • For adults, medical history, including serious accidents, illnesses and surgeries are recorded
  • For children, medical history, including prenatal care, birth, childhood illnesses and surgeries are recorded
  • The record includes notes about substance abuse and use of tobacco and alcohol
  • The record contains subjective and objective information about complaints
  • The record includes lab work and other studies that have been ordered as appropriate
  • Working diagnoses are consistent with findings
  • Treatment and action plans are consistent with findings
  • The record notes any follow-up care needed, including when follow-up is due
  • Unresolved problems from previous visits are addressed in subsequent visits
  • If a referral is made for consultation, a note from the consultant is included in the record
  • Consultation, lab and x-ray reports included in the record are initialed by the PCP, or some other means is used to indicate that they have been reviewed
  • The record contains evidence that appropriate immunizations, screenings and counseling have been provided in accordance with preventive health guidelines
  • Each entry is dated, legibly signed or typed and initialed by the service provider.
  • Identification of all providers participating in the member’s care and information on services furnished
  • Record and identify prescribed medications, including dosages and dates of initial or refill prescriptions
  • The record includes physical examinations, treatment necessary and possible risk factors for the member relevant to the particular treatment

Policy History

Date Action Reason
February 2013 Revised Revisions to strengthen language about provider signature.
May 2008 Revised Moved from PAP613

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