Medical Record Documentation Standards

Care1st’s goal is to assure each patient has a legible, detailed, well organized, confidentially stored, easily retrievable medical record. These records need to be consistent with standard medical and professional practice and meet the standards of oversight organizations, including Care1st Health Plan and regulatory agencies.

Care1st Health Plan recommends a six section format:


Section I

  1. Patient information sheet. This form should always be on top of all other forms in this section
  2. The signed general consent for treatment and all other consent forms (IUD, sterilization, surgery, etc.) must remain in the chart and should be placed in this section
  3. Authorization for release of medical records
  4. Copy of completed CHDP eligibility form
  5. Letters to and from the patient and/or his or her agent

Section II

HISTORY & PHYSICAL PROGRESS

Adult charts:

  1. Patient history/data base is/are the top forms filed in this section
  2. Problem List
  3. Medication Flow Sheet
  4. Immunization Flow Sheet
  5. Hearing/Vision Screen Record
  6. History and Physical Forms

Pediatric charts:

  1. CHDP Health Guidelines
  2. Age Specific Assessment Form
  3. Problem List Medication Flow Sheet
  4. Medication Flow Sheet
  5. Immunization Flow Sheet
  6. Hearing/Vision Screen Record
  7. Growth Charts
  8. Lead Screening Questionnaire
  9. Nutrition Screening Form
  10. Episodic Visit
  11. PM 160 Forms (CHDP forms)

Section III

LABORATORY

  1. Laboratory reports are to be filed in reverse chronological order, with the most current data on the top
  2. Reports of a size that will not mount on the form should be taped to a regular piece of paper and filed on a mounting form

Section IV

X RAY AND EKG

  1. File in reverse chronological order filing with EKG results segregated from each other

Section V

CONSULT/ REFERRAL

  1. File in reverse chronological order filing with EKG results segregated from each other
  2. Referral information, such as correspondence directed to an outside agency, physician, health facility, etc. regarding the medical information contained in his particular patient's medical record
  3. Copies of Requests for Referral/Consultation are filed in this section until the report is received, at which time the report is filed and the request is discarded
  4. Copy of medical records from previous medical Practitioners
  5. Hospital discharge summaries
  6. Emergency room records

Section VI

MISCELLANEOUS

  1. Complete OB records on inactive OB cases
  2. Correspondence with insurance companies or health plans
  3. Back to work or back to school forms
  4. Any reports, correspondence, forms, etc. that do not belong in another section

If it becomes necessary to start a new volume, label the new chart "Vol. II of II" and label the old chart "Vol. I of II". The following items should be carried forward to Volume II:

  1. Consent to treatment form
  2. Problem Index
  3. Most recent History and Physical form
  4. Pertinent history from previous Practitioners
  5. Most recent lab, x ray, EKG and progress notes