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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Medical Record Review Standards

PW_B133412

2010 Medical Record Standards

Office-Specific Questions
A documentation system is in place to follow up on missed appointments.
A system is in place to schedule appropriate preventive health services (i.e., reminder system).
Medical records are kept in a secure area away from public access, accessible only to authorized personnel.
Medical records are easily retrievable by office personnel, with legible file markers.
Written policy addresses confidentiality of patient information, with evidence that staff receives periodic training in member information confidentiality i.e., policy, training sessions log, etc.
Written policy addresses release of patient information and demonstrates confidentiality of all patient information in accordance with applicable state and federal laws, with evidence of continued office staff training on confidentiality.
Written policy addresses signed, informed consents; documentation is present and dated, when appropriate.
Written policy or statement in place relating to primary language and linguistic service needs of non-or-limited English proficient (LEP) or hearing-impaired members; such needs are prominently noted. Member refusal of interpreter services must be documented.
Written policy addresses that the office does not discriminate in the delivery of health care services by factors such as race, ethnicity, national origin, religion, sex, age, evidence of insurability, and accepts for treatment any member in need of the health care services they provide.
Written policy addresses prompt transfer of patient care records to other in- or out-of-plan providers for the member’s medical management.
Written policy addresses that medical records are retained for a period of 7 years after last patient encounter.
****SC SSB Only: Retention period is 10 years for adults and 13 years for minors. 
****GA Only: 6 years after the last patient encounter or 6 years after the patient turns age 18. 
Chart Elements/Content and Clinical Documentation
Every page in the record contains the patient name or ID number.
There is one chart per patient.
The chart is organized and the pages secured.
Biographical data include name, ID number, DOB, address, employer and address, home and work telephone numbers, emergency contact information, ethnicity, gender and marital status, as applicable, or the refusal to provide this information by the patient, parent or legal guardian, is noted in the medical record.
Missed or canceled appointments, along with follow-up contact and outreach efforts, is noted in the medical record.
Allergies/NKDA and adverse reactions are prominently displayed in a consistent location.
All presenting symptom entries are signed and dated, including phone entries. Dictated notes should be initialed to signify review. Signature sheet for initials are noted.
All presenting symptom entries are legible, including phone entries, to someone other than the writer. Signature sheet for initials are noted.
A problem list is maintained and updated for significant illnesses and medical conditions.
A medication list or reasonable substitute is maintained and updated for chronic and ongoing medications.
Past medical history is current and easily identified for patients seen 3 or more times and includes: family history, serious accidents, surgeries and illnesses. Childhood history includes prenatal care, birth operations and childhood illnesses. This information should be updated every 2 years.
For patients 11 years and older, appropriate notation appears annually concerning the use of cigarettes, alcohol and substances.
For patients 11 years to 21 or if relevant, there is appropriate notation concerning sex education, including such topics as abstinence, S.T.D., pregnancy prevention, use of condoms, etc.
History and physical exam identifies appropriate subjective and objective information pertinent to the patient’s presenting symptoms, and treatment plan is consistent with findings.
Laboratory tests and other studies are ordered, as appropriate, with results noted in the medical record within 14 calendar days of completion of services.
Encounter forms or notes have a notation, when indicated, regarding follow-up care, calls or visits. The specific time is noted in weeks, months or as needed.
Unresolved problems from previous office visits are addressed in subsequent visits.
Documentation of advance directive/Living Will/Power of Attorney discussion in a prominent part of the medical record for adult patients who are MA members; and documentation on whether or not the patient has executed an advance directive with a copy to be included in the medical record. (We also encourage providers to maintain documentation of advance directive discussions and copies of executed advance directives in patients’ files for other, non-MA members.)
Continuity and coordination of care between the PCP, specialty physician (including BH specialty) and/or facilities is shown. A summary of findings or discharge summary is requested and is in the medical record. Examples include progress notes/report from consultants, discharge summary following inpatient care or outpatient surgery, physical therapy reports, and home health nursing provider reports.
Physician reviews and follow-up is documented when needed on all consultants, lab and test results. (Evidenced by MD initials and date on results or consultant letter.)
Indication that the patient has been notified of abnormal test or lab results and explicit follow-up plans for all abnormal labs or test results.
Is there documentation of anticipatory guidance discussion regarding depression/anxiety, beginning at 7 years of age and/or sooner or at any time the physician feels the need for referral.
Depression/anxiety
Behavioral/developmental screening: general screening (i.e., PEDS or other tool) school readiness activities (risk level) for all ages.
Age appropriate routine preventive services/risk screening is consistently noted, i.e. childhood immunizations, adult immunizations, mammograms, pap tests, etc., or the refusal by the patient, parent or legal guardian, of such screenings/immunizations in the medical record.
For those patients with any of the following:
Diabetes
Post MI/Cardiac event
CAD
COPD
2 plus medical conditions
Is there evidence that the PCP screened for the presence of depressive symptoms? Please include the screening method (e.g., interview, use of tool, etc.). (Non-scored)
Is there evidence that the PCP screened for the presence of alcohol abuse symptoms? Please include screening method (e.g., CAGE, AUDIT, AUDIT-C, BMAST, TWEAK, medical history, progress note, other). (Non-scored)
Is there evidence that the PCP screened for depression? Please include the screening method (e.g., PHQ-9, HADS, GHQ, Beck, Zung, HAM-D, CES-D, Whooley, medical history, progress note). (Non-scored)
Health education appropriate to the patient is provided and documented in the medical record.
Errors are corrected according to legal medical documentation standards as follows:
Draw line through entry, the inaccurate information must remain legible.
Initial and date entry.
State the reason for the error (i.e., in the margin or above the note as room permits).
Document the correct information. Document the current date and time referring back to the incorrect entry.
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.