MHP follows nationally recognized standards for the maintenance of medical records within participating practitioner offices that support consistent and complete documentation of each member’s medical history and treatment. Appropriate documentation is an essential component of quality care. Protected Health Information (PHI) must be provided only to the extent permitted under state and federal law.
Medical records standards include the following, as applicable:
Patient name and/or identification (patient name, birth date, address and phone number) documented on each page;
All entries are dated;
Documentation by a treating physician of the Advance Directive disclosed by a patient;
All notes, reports, and records signed by the practitioner;
Completed problem list;
Allergies and adverse reactions prominently displayed. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record;
Medical history easily identified;
The history and physical examination identified appropriate subjective and objective information pertinent to a patient’s presenting complaints;
Working diagnoses consistent with findings;
For patients 14 and older, there is appropriate notation concerning the use of cigarettes, alcohol, and substances;
Treatment plans consistent with diagnosis;
Follow-up care or calls documented and dated;
Unresolved problems from previous office visits are addressed in subsequent visits;
Consults, labs, and tests reflect physician review with follow-up if abnormal. The ordering practitioner initials each report filed in the chart;
There is no evidence the patient is placed at inappropriate risk by a diagnostic or therapeutic procedure; and
An immunization record is up to date.
Medical records must be made available to MHP for utilization management, quality management, disease management, discharge planning, case/care management, and/or claims payment purposes. The medical records requested will be necessary for the specific case to audit and/or certify medical necessity / appropriateness of an admission or extension of stay, frequency or duration of service. In addition, authorized representatives from the Health Department, the Department of Health and Human Services, and/or CMS are allowed access to medical records of Mercy MedicareADVANTAGE members for specific purposes.
To facilitate the process, all members sign a release of medical information as part of their enrollment process. This release is in effect for the duration of their status as MHP plan members.
Providers may request and receive reimbursement for chart copies according to their provider agreement.
For a minimum of 7 years from the date when the last professional service was provided, the medical record must remain under the care, custody, and control of the practitioner.
Required documentation in the chart includes all services provided directly by the practitioner and, if applicable, all ancillary services and diagnostic tests ordered by the practitioner, and all diagnostic and therapeutic services for which the member was referred by the practitioner (e.g., home health nursing reports, specialty physician reports, and physical therapy reports). A consultative report shall be considered an adequate medical record for a radiologist, pathologist, or a consulting physician.
Any correction, addition, or change in any patient record made more than 48 hours after the final entry in the record is signed by the practitioner, shall be clearly marked and identified as such. The date, time, and name of the person making the correction, addition, or change shall be included, as well as the reason for the correction, addition, or change.
Upon request by patient changing practitioners, copies of the medical records must be forwarded to the new practitioner in a manner that facilitates continuity of care.