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  • Medical Record Guidelines > Medical Record Content and Format

    Each member should have a unique medical record, which contains at least the following information:

    PCP Coordinates Care

    Where the member's plan requires PCP assignment, the record verifies that the PCP coordinates and manages the member's care.

    Personal

    • Name
    • EmblemHealth ID number
    • Date of birth
    • Address and phone number
    • Employer's name, address and phone number
    • Marital status
    • Benefit plan participation and copayment (if applicable)
    • Name of the primary care physician (PCP)
    • List of allergies and/or adverse reactions, or "No Known Allergies" (NKA)

    Medical

    • 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 PCP must also clearly document any follow up on the member's ER visit and/or hospitalization, whether an office visit, written correspondence, or telephone conversation.

    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 jacket, reports of similar type (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 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, 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 review 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

    The Centers for Medicare and Medicaid Services (CMS) requires each date of service in a member's medical record to be accompanied by a legible provider signature and credentials. Some examples of appropriate credentials are MD, DO and Ph.D. In general, for your medical records to be deemed compliant, you must authenticate each note for which services were provided. Acceptable physician authentication includes handwritten and electronic signatures or signature stamps. Please review the tables that follow for examples of acceptable and unacceptable signatures and credentials.

    ACCEPTABLE PHYSICIAN SIGNATURES AND CREDENTIALS
    Signature Type Acceptable

    Handwritten signature or initials, including credentials

    • Mary C. Smith, MD or John J. Smith, DO or, for initialing MCS, MD or JJS, DO

    Signature stamp, including credentials

    • Must comply with state regulations for signature stamp authorization

    Electronic signature, including credentials

    • Must be password protected and used exclusively by the individual physician
    • Requires authentication by the responsible physician, statements including but not limited to:
      • Approved by
      • Signed by
      • Electronically signed by
    UNNACCEPTABLE PHYSICIAN SIGNATURES AND CREDENTIALS WITH CORRECTIVES
    Signature Type Unacceptable Unless

    Provider signature without credentials

    • Name is linked to provider credentials or name on physician stationary

    Typed name

    • Name is authenticated by the provider

    Signed by a non-physician or a non-physician extender (e.g., medical student)

    • Signature is co-signed by responsible physician

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    Glossary terms found on this page:

    An activity of EmblemHealth or its subcontractor that results in:

    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
    • Denial, in whole or in part, of payment for a service
    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    An agreement in which a patient assigns to another party, usually a physician or hospital, the right to receive payment from a public or private insurance program for the service the patient has received.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    The government agency responsible for administering the Medicare and Medicaid programs.

    Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:

    • A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
    • Treatment experienced through the plan, its providers or contractors
    • Any concern with the plan, its benefits, employees or providers.

    Services rendered by a physician whose opinion or advice is requested by another physician for further evaluation or management of the patient.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    The date on which a service was rendered.

    A test or procedure ordered by a physician to determine if the patient has a certain condition or disease based upon specific signs or symptoms demonstrated by the patient. Such diagnostic tools include radiology, ultrasound, nuclear medicine, laboratory and pathology services.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

    • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
    • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
    • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
    • Maintains medical records for all patients
    • Has a requirement that every patient be under the care of a member of the medical staff
    • Provides 24-hour patient services
    • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

    A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.

    Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

    A written order or refill notice issued by a licensed medical professional for drugs available only through a pharmacy.

    Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, and generally including routine physical examinations and immunization.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

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