Practitioner office documentation

Consistent and complete documentation in the medical record is essential for high-quality patient care. In addition to compliance with basic and sound principles of complete record keeping, records must document a process of medical care and patient education.

View the complete documentation review standard for the requirements for medical records and procedure/surgical notes.

Specific documentation requirements

Systems for handling and keeping medical records

  • The practitioner office must maintain separate medical records for each member seen.
  • The medical record must be part of an organized medical record-keeping system and easily retrievable for review.
  • Medical records must be retained in accordance with state law.
  • Medical records will be made available to Priority Health as indicated in the provider contract.
  • When a member changes his/her Primary Care Practitioner, his/her medical records or copies must be forwarded to the new Primary Care Practitioner within 10 working days from receipt of the request.
  • Medical records must be stored away from patient care areas.

Confidentiality

  • Each practitioner must maintain a Notice of Privacy Practice in order to maintain HIPAA compliance.
  • Employees must protect computer-processed patient or provider care information with the same diligence as the original health record (e.g., identification of authorized users; use of security codes; and location of computer facility in a limited access area).
  • The office must maintain back-up files for all current information system data off-site or in a separate secure geographic location.
  • As applicable, the office must obtain written agreements from the computer vendors involved with patient or practitioner health care data that mandate the security of computerized data classified as confidential, and specify the methods by which employees are to handle and transport such information.
  • Medical records must be stored away from patient care areas, in a place where persons other than staff cannot view them.
  • Employees must maintain confidentiality at all points: during collection of the information, when and where it is stored with limited access and disclosure including eventual disposal.

These guidelines encompass standards from:

  • National Committee for Quality Assurance
  • Michigan Department of Insurance and Financial Services (DIFS)
  • Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) criteria