Medical Record Maintenance: The importance of compliance

Patient care and the revenue cycle management revolves around medical records.  It is the only documented proof of what took place during the patient’s visit.

For accurate reporting on diagnosis codes, the medical record documentation must best describe the patient’s condition. This should include a specific diagnosis, symptoms, problems, or reasons for the visit. The provider is responsible for making sure ICD coding adheres to ethical standards. Member charts are subject to review and are often asked for by all insurance.

We require your cooperation in this regard.

Medical Record Quality

  • Maintain your medical records in a manner that is current, detailed and organized.
    • This allows for effective and confidential patient care and quality reviews.
  • Medical Records must be accurately written, promptly completed and filed, retained and accessible
  • Medical Records must be complete, retained and accessible 24 hours a day
    • If an emergency department physician needs to see old records of a patient at 3 am, someone should be able to access those records.

Timeliness of Documentation

It is expected that documentation will be generated at the time a service is rendered or “as soon as practicable after it is provided to maintain an accurate medical record”.

  • A reasonable expectation would be no more than 24-48 hours away from the service itself.
  • Delayed entries within a reasonable time are acceptable for purposes of clarification, error correction, addition of information not initially available, or if unusual circumstances prevented the generation of the note at the time of service.
  • Anything after 48 hours may be considered unreasonable
    • providers cannot be expected to recall specifics of services rendered after time has passed.
  • Entries should never be made in advance of a service being rendered.

Medical Record Contents

  • All entries must be legible, complete, dated and timed and authenticated by the person responsible for ordering, providing, or evaluating the service provided
    • The record is legible to someone other than the writer
  • Patient’s complaint or reason for the visit
  • Past medical, behavioral, social, and vaccination history
    • Tobacco habits, including advice to quit, alcohol use and substance use (age 11 and older)
    • Immunization record
    • Preventive screenings/services and risk screenings
    • Blood pressure, height and weight, body mass index
    • Physical assessment for each visit
    • Growth charts for children and developmental assessments
    • Physical activity and nutritional counseling
  • Physical assessment
  • Unresolved problems from previous visit
  • Include the name of current medications, dosages, and over-the-counter drugs.
  • List medication allergies and adverse reactions.
    • Note if the patient has no known allergies or adverse reactions. This is critical.
  • Reflect all services provided, tests ordered, and all diagnostic/therapeutic services referred by the provider.
  • Diagnosis and treatment plans
  • Support the diagnosis
  • Medical Records must describe the patient’s response to intervention, care, and treatment
  • Patient education, counseling or coordination of care with other care providers
  • Date of return visit or other follow-up care, including phone calls
  • Review by the primary care provider on consultation, lab, imaging, special studies, and ancillary, outpatient and inpatient records
  • Follow-up care plans
    • Encounter forms or notes have a notation, regarding follow-up care, calls or visits, when indicated. The specific time of return is noted in weeks, months or as needed.
  • When coding the encounter, pick the Evaluation and Management (E&M) level from the patient’s condition at the time of the visit.