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Provider Manual

Documentation of Care

Last Updated on September 17, 2018

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

  • 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. Provider Rights and Responsibilities Provider/Facility Manual Security Health Plan 08-11
  • 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.