Medical Record Documentation

UPMC Health Plan requires participating network physicians to maintain medical records for their members in a manner that is:

• Accurate and timely
  
  
• Well-organized, readily accessible, and confidential
  
  
• Designed to permit prompt and systematic retrieval of information
  
  
• Maintained in a secure location that can be locked and protected when not being used
  

The medical record must express the evaluation and treatment of the member in a legible and detailed manner to assist communication, coordination, and continuity of care and to promote efficient and effective treatment. Consistent and complete documentation in the medical record is an essential component of quality patient care. The Health Plan has adopted certain standards for medical record documentation. To meet these guidelines, a provider should:

Basic Information

• Place the member's name or ID number on each page of the record.
  
  
• Include marital status and address along with name of employer and home and work telephone numbers.
  
  
• Include the author's identification in all entries in the medical record. The author identification may be a handwritten signature, unique electronic identifier, or initials.
  
  
• Date all entries.
  
  
• Ensure that the record is legible to someone other than the writer.
  
  

Medical History

• Indicate significant illnesses and medical conditions on the problem list. If the patient has no known medical illnesses or conditions, the medical record includes a flow sheet for health maintenance.
  
  
• Prominently note medication allergies and adverse reactions in the record. If the patient has no known allergies or history of adverse reactions, providers appropriately note this in the record.
  
  
• Document in an easily identifiable manner past medical history (for members seen three or more times), which may include serious accidents, operations, and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations, and childhood illnesses.
  
  
• Note for members 14 years and older the use of cigarettes, alcohol, and substances. (For members seen three or more times, query substance abuse history).
  
  
• Identify appropriate subjective and objective information in the history and physical exam that is pertinent to the member's complaints.
  
  
• Maintain an updated immunization record for children or add appropriate history to the medical record for adults.
  
  
• Include evidence that the provider offered preventive screening and services in accordance with the organization's practice guidelines.
  
  
• Include, when applicable, summaries of emergency care, hospital admissions, operative procedures, and reports on any excised tissue.
  
  
• Discuss advanced directives and, if completed, maintain a copy of the directives in the medical record.
  

Treatment

• Provide an indication that laboratory and other studies were ordered, as appropriate.
  
  
• Provide an indication that working diagnoses are consistent with findings.
  
  
• Provide an indication that treatment plans are consistent with diagnoses.
  
  
• Document progress notes, treatment plans, and any changes in a treatment plan, including drugs prescribed.
  
  
• Document prescriptions telephoned to a pharmacist.
  
  
• Address unresolved problems from previous office visits in subsequent visits.
  

Notations

• Include on encounter forms or notes a notation regarding follow-up care, calls, or visits. Providers note the specific time of recommended return visit in weeks, months, or as needed.
  
  
• Keep documentation of follow-up for any missed appointments or no-shows.
  
  
• Include a note from the consultant in the medical record for cases in which the provider requests a consultation.
  
  
• Place initials on reports filed in the chart to signify review of consultation, lab, and imaging work. Review and signature by other professionals, such as a nurse practitioner or physician assistant, does not meet this requirement. Consultation, abnormal lab, and imaging study results must have an explicit notation of follow-up plans in the record.
  

The Health Plan routinely reviews medical records to ensure that they comply with the above guidelines and that there is no evidence in the records that a member was placed at inappropriate risk by a diagnostic or therapeutic procedure.