Sunflower Health Plan providers must keep accurate and complete medical records. Such records will enable providers to render the highest quality healthcare service to members. They will also enable Sunflower Health Plan to review the quality and appropriateness of the services rendered. Sunflower Health Plan will conduct random medical record audits as part of its QI program to monitor compliance with the medical record documentation standards.
The coordination of care and services provided to members, including over/under utilization of specialists, as well as the outcome of such services also may be assessed during a medical record audit. Sunflower Health Plan will provide written notice prior to conducting a medical record review.
Medical Record Maintenance
Consistent and complete documentation in medical records is an essential part of quality care. We ask that participating practitioners keep uniform and organized medical records that contain member demographics and medical information regarding services rendered.
Medical records must be maintained in an organized system in compliance with our medical documentation and record-keeping standards. The intent with these standards is to help practitioners maintain complete medical records for all members, consistent with industry standards, and to meet state contract requirements.
A complete medical record must be maintained on each member for whom the practitioner has rendered healthcare services. These records must be protected from public access and any information released must comply with HIPAA guidelines.
Upon request, all participating practitioner medical records must be available for utilization review and QI studies – including HEDIS – as well as regulatory agency requests and member relations inquiries, as stated in the provider agreement.
Additionally, practitioners must provide a copy of a member’s medical record upon reasonable request by the member at no charge.
The following is a list of the minimum required standards for practitioner medical record-keeping practices:
Organization and Confidentiality
- Records are organized and stored in a manner that allows easy retrieval.
- Records are stored in a secure manner that allows access by authorized personnel only.
- Staff receive periodic training in member information confidentiality.
Records should include:
- Patient identification information (patient name or identification number) on each written page or electronic file record.
- Identity of the provider rendering the service.
Records should include:
- All services provided directly by a practitioner who provides primary care services.
- Date that the service was rendered.
- All ancillary services and diagnostic tests ordered by the practitioner.
- Explicit notations in the record for follow-up plans for abnormal lab and imaging study results; all entries should be initialed and dated by the ordering practitioner to signify review.
- Documentation of all diagnostic and therapeutic services for which a member was referred to by a practitioner, including follow-up of outcomes and summaries of treatment rendered elsewhere such as: home health nursing reports, specialty physician reports, hospital discharge reports (emergency room and inpatient) and physical therapy reports.
- History and physicals.
- Allergies and adverse reactions (prominently documented in a uniform location).
- Problem list.
- Immunization records.
- Documentation of clinical findings and evaluation for each visit (including appropriate treatment plan and follow-up schedule).
- Preventive services / risk screenings provided.
- Documentation of health teaching, counseling and/or age appropriate anticipatory guidance.
- Advance directives.
- Documentation of failure to keep an appointment.
- Documentation of physical health medical record information sent to behavioral health providers, if applicable.
- Documentation of cultural, interpretation or linguistic needs; if not applicable, then documented as N/A.