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Medical Record Standards

Complete and consistent documentation in patient medical records is an essential component of quality patient care. Keystone First Community HealthChoices adheres to medical record requirements that are consistent with national standards on documentation and applicable laws and regulations.

The Plan performs an annual medical record review on a random selection of practitioners. The medical records are audited using these standards.

  • Elements in the medical record are organized in a consistent manner, and the records are kept secure and confidential.
  • Patient's name or identification number is included on each page of record.
  • All entries are legible, initialed or signed and dated by the author.
  • Personal and biographical data are included in the record.
  • Current and past medical history and age-appropriate physical exams are documented including serious accidents, operations and illnesses.
  • Allergies and adverse reactions are prominently listed or noted as "none" or "NKA."
  • Information regarding personal habits such as smoking and history of alcohol use and substance abuse (or lack thereof) is recorded when pertinent to proposed care and/or risk screening.
  • An updated problem list is maintained.
  • Documentation of discussions of a living will or other advance directive for patients 65 years or older
  • Patient's chief complaint or purpose for visit is clearly documented.
  • Clinical assessment and/or physical findings are recorded. Appropriate working diagnoses or medical impressions are recorded.
  • Plans of action/treatment are consistent with diagnosis.
  • There is no evidence the patient is placed at inappropriate risk by a diagnostic procedure or therapeutic procedure.
  • Unresolved problems from previous visits are addressed in subsequent visits.
  • Follow-up instructions and time frame for follow-up or the next visit are recorded as appropriate.
  • Current medications are documented in the record, and notes reflect that long-term medications are reviewed at least annually by the Network Provider and updated as needed.
  • Health care education provided to patients, family members, or designated caregivers is noted in the record and periodically updated as appropriate.
  • Screening and preventive care practices are in accordance with the Plan’s Preventive Health Guidelines.
  • An immunization record appropriate history has been made in the medical record.
  • Requests for consultations are consistent with clinical assessment/physical findings.
  • Laboratory and other studies are ordered, as appropriate.
  • Laboratory and diagnostic reports reflect Network Provider review.
  • Patient notification of laboratory and diagnostic test results and instruction regarding follow-up, when indicated, are documented.
  • There is evidence of continuity and coordination of care between PCPs and specialists.
  • Document all therapies and other prescribed regimens.
  • Document disposition and follow-up.
  • Document referrals and results.
  • Services provided as per the Patient-Centered Service Plan for Participants who have one.
  • Service coordination contact notes as applicable.