Medical Record Guidelines
The 1199SEIU Benefit Funds require practitioners to maintain accurate medical records. The medical record contains information about each member; identifies their complaints/symptoms or lack thereof; and contains both the diagnosis and the basis for the diagnosis, as well as the communication and discussion of treatment options, side effects, decisions made and treatments rendered. The primary purpose of the record is to document the course of the member’s health or illness and treatments and serve as a mode of communication between physicians and other professionals participating in the care rendered. The entire medical record of a member must remain in the rendering practitioner’s office and must be compliant with all relevant local, state and federal laws, rules and regulations.
The following guidelines assist the 1199SEIU Benefit Funds in ensuring appropriate exchange and retention of member medical data and are used to perform clinical audits in conjunction with ongoing quality assurance activities.
Please note that the Benefit Funds may request a copy of, or make an onsite visit to review, your medical records for internal or regulatory purposes.
Medical Record Content
Each member is required to have a unique medical record, which contains at least the following information:
- Member ID number
- Date of birth
- Address and phone number
- Employer’s name, address and phone number
- Marital status
- Name of primary care physician (PCP)
- List of allergies and/or adverse reactions or a “no known allergies” (NKA) notation
- Copy of the member’s Health Benefits ID card and photo identification
- Biographical information
- Comprehensive baseline history and physical (see details below)
- Diagnostic test results
- Consult reports
- Progress notes
- Medication records
- Problem list
- Allergy documentation
- Telephone/communication log
- Immunization records
- Preventive health screening records
- Inpatient/ER discharge summary reports, if applicable
- Operative reports, if applicable
The comprehensive baseline history and physical must include a review of:
- Subjective and objective complaints/problems
- Family history
- Social history (i.e., occupation, education, living situation, risk behaviors)
- Significant accidents, surgeries, illnesses and mental health issues
- Complete and comprehensive review of systems (including patient’s presenting complaint, as applicable)
- Prenatal care and birth information (baseline, 18 years and younger only); in cases where the member has both a PCP and an OB/GYN, they must coordinate to ensure there is a centralized medical record for the provision of prenatal care and all other services
Periodic history and physicals review should be repeated in accordance with age-appropriate preventive care guidelines.
Within the record, similar reports (i.e., progress notes, laboratory reports) should be filed together in chronological or reverse chronological order, permitting easy retrieval of information, and initialed by the physician to indicate they have been read. Each progress note filed should be legibly written or typed, signed and dated by the author and contain at least the following items:
- The reason for the visit, as stated by the member
- The duration of the problem
- Findings on physical examination
- Laboratory and X-ray results, if any
- Diagnosis or assessment of the member’s condition
- Therapeutic or preventive services prescribed, if any
- Dosage, duration and side effect information of any prescription given, with medication allergies and adverse reactions noted prominently (updated during a physical, when a prescription is written or annually, whichever comes soonest)
- Follow-up plan (including self-care training) or that no follow-up is required
Reports generated as a result of a request for a test or consultation must be filed immediately in the medical record with the member’s name, member ID number and date of birth on each document page.
Test results should be reported to the member within a reasonable time after physician receipt and reviewed and filed with a progress note indicating when the member was notified, by whom and the next steps in the treatment plan.
Provider Signature Attestation
Each date of service in a member’s medical record is to be accompanied by a legible provider signature and credentials. Some examples of appropriate credentials are MD, DO and PhD. In general, for your medical records to be deemed compliant, you must authenticate each note for which services were provided. Acceptable provider authentication includes handwritten and electronic signatures. Signature stamps are not acceptable.
For electronic signatures, the signature must be password protected and used exclusively by the individual physician or rendering provider. The electronic signature also requires authentication by the responsible rendering provider with statements like, but limited to, approved by; signed by; or electronically signed by.
The following text summarizes sections of the Practitioner Participation Agreement (the legal agreement between the 1199SEIU Benefit Funds and the practitioner) pertaining to medical records:
Maintenance of medical records
Practitioner shall maintain member medical records, and related financial and administrative records, that are accurate, complete, up to date, organized and otherwise in conformance with federal and state laws, accreditation requirements and good industry practice, so as to permit effective patient care, quality review and administration of the Plans. Such records shall be retained by the practitioner for at least the minimum periods of time required by such laws, requirements and practices.
Access to medical records
Upon prior written notice and during normal business hours, the practitioner shall make available to the Benefit Funds for inspection and copying, at no cost to the Benefit Funds, all member medical information, as well as financial and administrative data. The Benefit Funds warrant to the practitioner that members have agreed to release of their medical and administrative records to the Benefit Funds, and the practitioner agrees that the Benefit Funds will not be required to obtain additional releases from members before inspecting, reviewing or copying such records.