The medical record should identify the member’s complaints/symptoms, diagnosis, basis for the diagnosis, treatment plan(s) consistent with diagnosis, historical medications and treatment, members’ needs, barriers, strengths, and limitations. It also should include the discussion of treatment options, side effects, decisions made, and treatments rendered.
All entries in a medical record must:
- Have the author’s identification: a handwritten signature, unique electronic identifier, or initials.
- Have a date of service.
- Is complete and legible to someone other than the writer.
Primary Care Physician (PCP) – Coordination of Care
The record verifies that the PCP coordinates and manages the member's care. In cases when a member’s benefit plan does not require a PCP assignment, the primary physician managing the member’s care would coordinate that care. Each member should have a unique medical record that contains at least the following information:
- Name on each page in the medical record
- EmblemHealth ID number on each page in the medical record
- 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)
- Patient’s self-reported race, ethnicity, and preferred language
- Comprehensive baseline history and physical (see details below)
- Diagnostic test results
- Consult reports
- Progress notes
- Medication records, including medications, dosage, frequency, dates of initial and/or refill prescriptions, over-the-counter medications, supplements, etc.
- Problem list, including but not limited to past medical history, chronic or significant ongoing acute medical conditions, significant surgical conditions, and significant behavioral health conditions.
- Allergy and/or adverse reactions to drugs documentation. Note if no known allergies and/or adverse reactions.
- 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)
- Social determinants of health
- Cultural needs including family, social, religious, literacy
- Cognitive abilities
- Psychosocial emotional health and prior treatment
- Reports from other physicians and treatment including vision, hearing, information from specialists, facilities
- Family support
- 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 reviews of history and physicals should be repeated in accordance with age-appropriate preventive care guidelines.
Within the record (electronic or paper), 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 and actions) or that no follow-up is required
- Time to next visit and other follow-up appointments
Reports generated in response to 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 the physician receives, reviews, and files with a progress note indicating when the member is notified, by whom, and the next steps in the treatment plan.
Provider Signature Attestation
The Centers for Medicare & 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 PhD. For your medical records to be deemed compliant, you must authenticate each note for which services are 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.