Medical Record Requirements

This is an outline of the required medical record documentation needed to demonstrate compliance with state-required medical record documentation standards.

Documentation Standards for Medical Record Requirements

The medical record organization and documentation shall, at a minimum, require the following:

• Member identification information on each page
• Personal/biographical data, including:
  • Date of birth
  • Date of data entry and date of encounter
  • Provider identification by name
  • Allergies, adverse reactions and any known allergies are noted in a prominent location in the record
  • Past medical history, including serious accidents, operations, illnesses. For children, past medical history includes prenatal care and birth information, operations, and childhood illnesses (i.e. documentation of chickenpox)
  • Identification of current problems
  • The consultation, laboratory, and radiology reports filed in the medical record shall contain the ordering provider’s initials or other documentation indicating review
  • Behavioral health summary reports as applicable, initial evaluation and routine follow up consultations
  • Documentation of immunizations pursuant to 902 KAR 2:060
  • Identification and history of nicotine, alcohol use or substance abuse
  • Documentation of reportable diseases and conditions to the local health department serving the jurisdiction in which the member resides or Department for Public Health pursuant to 902 KAR 2:020 as applicable
  • Follow-up visits provided secondary to reports of emergency room care as applicable
  • Hospital discharge summaries as applicable
  • Advanced medical directives for adults. PCPs have the responsibility to discuss advance medical directives with adult members at the first medical appointment and chart that discussion in the medical record of the member
  • All written denials of service and the reason for the denial as applicable
• Signature of the provider conducting the encounter
• Record legibility to at least a peer of the writer. Records judged illegible by one reviewer are evaluated by another reviewer

In addition, a member’s medical record shall include the following minimal detail for individual clinical encounters:

• History and physical examination for presenting complaints containing relevant psychological and social conditions affecting the member’s medical/behavioral health, including mental health, and substance abuse status
• Unresolved problems, referrals and results from diagnostic tests including results and/or status of preventive screening services (i.e. EPSDT) are addressed from previous visits
• Plan of treatment that includes:
  • Medication history, medications prescribed, including the strength, amount, directions for use and refills
  • Therapies and other prescribed regimen
  • Follow-up plans including consultation and referrals and directions, including time to return