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Provider Manual

Documentation of Care

Last Updated on January 24, 2019

Providers are required to maintain a medical record for all Medicare Advantage members. The following are Security Health Plan’s Medical Record Documentation Standards:

  • For patients 65 years of age or older, an advance directive is documented in a prominent part of the medical record, and there is an indication whether the member has executed an advance directive. 
  • Each page in the medical record contains patient identification. 
  • Medical record (paper or computer) includes personal biographical data including the address, employer, home and work telephone numbers, emergency contact person, and marital status. 
  • All entries in the medical record have author identification. 
  • All entries are dated. 
  • The record is legible by someone other than the writer. Any record considered not legible will be reviewed by a second reviewer. 
  • Significant illnesses, medical conditions, and medications are indicated on the problem list. 
  • Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies (NKDA), this is appropriately noted in the medical record. 
  • Past medical history is easily identified and includes serious accidents, illnesses, and operations. 
  • For patients 14 years of age and older there is appropriate notation concerning the use of alcohol, tobacco, and other substances in the past two years. 
  • History and physical exam records contain appropriate subjective and objective information pertinent to the patient’s presenting complaints. 
  • Laboratory and other studies are ordered as appropriate. 
  • Working diagnoses are consistent with findings. 
  • Treatment plans are consistent with diagnoses. 
  • There is a date for return visit or other follow-up plan for each encounter. 
  • Problems from the previous visit(s) are addressed. 
  • There is evidence of appropriate use of consultants, and continuity and coordination of care, between primary and specialty physicians. 
  • Consultant summaries, lab and imaging studies results reflect primary care physician review. 
  • There is no evidence that the patient is placed at an inappropriate risk. 
  • There is evidence that preventive screening and services have been provided
    • High risk adults and those over 65 have an up-to-date immunization record/history 
    • There is an up-to-date immunization record (0 – 19 years of age) 
    • Patient and/or family member education is appropriate for the patient’s history and risks 
    • There is periodic screening for high blood pressure and other cardiovascular risk factors (cholesterol 35 years of age and above and blood pressure 20 years of age and above) 
    • Mammograms every two years (ages 50 – 69) 
    • Pap test every three years (as appropriate) 
    • There are six or more well-child visits (0 – 15 months of age) 
    • There are annual well-child visits (2 – 6 years of age) 
  • For patients who had an ambulatory surgery procedure, there is a copy of the operative report. 
  • There is a discharge summary and/or treatment plan for patients requiring home health services. 
  • There is a discharge summary or other appropriate communication for patients being discharged to a skilled nursing facility. 
  • There is a discharge summary or other appropriate communication for patients being discharged from the hospital.