Medical records and documentation standards

The purpose of complete and accurate patient record documentation is to foster quality and continuity of care. It creates a means of communication between providers and between providers and members about health status, preventive health services, treatment, planning, and delivery of care.

Medical records standards

Our medical record standards reflect the importance of confidentiality and accessibility by authorized users only.

We require you to:

• Keep a unique, individual record for each patient
• Establish an organized record-keeping system to ensure that medical records are easily retrievable for review and available for use when needed, including at each patient visit
• Store and maintain medical records in a centralized and secured location accessible only to authorized personnel and provide equivalent security for electronic medical records
• Maintain and organize documents within medical records in a specified order
• If there is a paper medical record, ensure that documents are fastened securely within a paper medical record
• Provide periodic training in confidentiality and security for patient information
• CMS requires Medicare managed program providers to retain medical records for 10 years. Kaiser Permanente follows CMS standards for medical records retention.

Providing documentation of referral encounters

Whenever a Kaiser Permanente or contracted provider (other than a member's personal physician) sees a Kaiser Permanente member, complete documentation of the encounter must be made available to the referring provider and the member's personal physician. If the documentation is not added directly to the Kaiser Permanente electronic medical record, copies of the relevant medical records must be provided within five working days of the visit.

Promptly forwarding the records ensures that the personal physician has a complete medical record on file and that the referring provider has necessary information.

Documentation standards

Our documentation standards reflect the importance of complete, timely, and accurate health information.

Kaiser Permanente expects the following concerning documentation:

• Member identifiers appear on every piece of documentation
• Entries are legible to others and are recorded in black or blue ink if on paper
• Entries are dated and authenticated by the author
• Documentation is made at the time service is provided
• Documentation must support all codes submitted
• Only standard medical abbreviations should be used in documentation
• All patient encounters, including telephone, fax, and electronic message exchanges are documented
• Documentation of any advance directives is in a prominent part of a member's medical record and includes whether or not a member has executed an advance directive, as well as documentation of any information about advance directives that was made available to the member

Documentation must include the following content:

• Problem list, including significant illnesses and medical conditions
• Medications
• Adverse drug reactions
• Allergies
• Smoking status
• Any history of alcohol use or substance abuse
• Biographical or personal data
• Pertinent history
• Physical exams
• Documentation of clinical findings and evaluation for each visit
• Laboratory and other studies that signify review by the ordering provider
• Working diagnoses consistent with findings and test results
• Treatment plans consistent with diagnoses
• A date for return visits or a follow-up plan for each encounter
• Previous problems addressed in follow-up visits
• A current immunization record
• Preventive services and risk screening

Primary care medical records must document:

• All services provided by a practitioner who provides primary care services
• All ancillary services and diagnostic tests ordered by a practitioner
• All diagnostic and therapeutic services for which a member was referred by a practitioner, such as home health nursing reports, specialty physician reports, hospital discharge reports, or physical therapy reports

During documentation reviews, we will measure for attainment of the following performance goals:

• 80 percent of charts have an updated problem list
• 80 percent of charts have documentation of allergies
• 80 percent of charts have documentation of immunizations

During the review, we take advantage of the opportunity to collect meaningful clinical-performance information that otherwise is difficult to obtain. We strive to minimize our impact on you during the reviews, but we also are committed to creating useful measurement and feedback tools for all providers in our network.