Medical Record Documentation Standards
Consistent and complete documentation in the medical record is an essential component of providing quality patient care. Participating practitioners are required to maintain uniform, organized medical records that contain patient demographics and medical information regarding services rendered to members. Medical records must be maintained in an organized medical record-keeping system in compliance with the MHS medical documentation and record-keeping practice standards. These standards are intended to assist providers in maintaining complete medical records for all members, and are consistent with state contract requirements and National Committee for Quality Assurance (NCQA) accreditation standards.
A complete medical record must be maintained for each member for whom the pracitioner has provided health care services and in accordance with accepted professional practice standards, state, and federal requirements. Records must have documentation of all services provided directly by the practitioner who provides primary care services and be retained and kept confidential by the practitioner for at least seven (7) years.
Medical records and information must be protected from public access and any information released must comply with Health Insurance Portability and Accountability Act (HIPAA) guidelines. Upon request, all participating practitioners’ medical records must be available for utilization review and quality improvement studies, as well as regulatory agencies’ requests and member relations’ inquiries, as stated in the practitioner agreement. Medical records must be available at the practice site for other practitioners who provide care and services to the patient. MHS providers must provide a copy of a member’s medical record upon reasonable request by the member at no charge, and the provider must facilitate the transfer of the member’s medical record to another provider at the member’s request.
The minimum required standards for practitioner medical record keeping practices, which include medical record content, medical record organization, ease of retrieving medical records, and maintaining confidentiality of patient information, are outlined in the MHS Provider Manual.
For MHS Medical Record Documentation Standards, see Chapter 18 of the MHS Provider Manual, available on the Provider Guides page.
View the Medical Record Documentation Audit Tool on the Provider Guides page.