Medical Records
Nebraska Total Care 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 Nebraska Total Care to review the quality and appropriateness of the services rendered. Nebraska Total Care 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. Nebraska Total Care 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.
Following is a list of the minimum required standards for practitioner medical record-keeping practices.
- 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.
- Member–identifying information: name, member ID number, date of birth, gender, legal guardianship
- Primary language spoken and/or translation needs
- Services provided including date of service, service site, and name of service provider
- Medical history, diagnosis, treatment and therapies prescribed, drugs administered or dispensed
- Referrals including follow-up and outcome of referrals
- Documentation of emergency or after-hours encounters and follow-up
- Signed and dated consent forms (as applicable)
- Advance directive documentation
- Date, and begin/end times of service
- Chief complaint or purpose of visit
- Diagnosis or medical impression
- Objective findings
- Studies ordered and result of studies (e.g., laboratory, x-ray, EKG)
- Medications prescribed
- Health education provided
- Name and credentials of provider rendering service (e.g., MD, DO, OD) and the signature or initials of the providers
- Comprehensive health history
- Developmental history
- Unclothed physical exam
- Vision, hearing and dental screening
- Immunizations
- Lab testing including mandatory lead screening
- Health education and anticipatory guidance