10.07.11.05

.05 Medical Records.

A. The HMO shall maintain an individual record for each patient according to accepted professional principles and the provisions of these regulations, with entries kept current, dated, and signed by a physician or other medical professional.

B. All information contained in the medical records and information received from physicians, surgeons, certified nurse practitioners, or hospitals, incident to the health care practitioner-patient or hospital-patient relationship, shall be kept confidential, and, except for use incident to bona fide medical research and education, or for the Department's review under these regulations, or as reasonably necessary in connection with the administration of the member's contract, may not be disclosed without the consent of the patient.

C. Contents and Procedures. The medical record shall contain at least the following information and be maintained under the following procedures:

(1) Identification and summary sheets;

(2) Prior medical findings and referral information;

(3) Information necessary to support the diagnosis and justify the treatment given as shown in the individual written plan of treatment;

(4) Progress notes by a medical staff member, as appropriate; a physician shall review and approve the progress notes within 24 hours of entry;

(5) Dated record of all treatments, medications, laboratory tests, X-rays, operative reports, anesthesia records, and measurements;

(6) Consultation report, if appropriate;

(7) Record of any emergency care treatment rendered to patient; and

(8) Discharge summary of inpatient hospitalization to include condition at time of discharge and post operative instructions given to the patient.

D. It is the responsibility of each attending clinical staff member to complete and sign the medical records of each ambulatory patient the staff member treats, within 72 hours of treatment.

Agency Note: The requirements of other related health programs will be considered when reviewing this requirement.

E. The HMO shall maintain a system for identifying and filing records which provides for:

(1) A universal identifier; and

(2) Adequate space and equipment for filing and prompt retrieval of medical records.

F. The HMO shall have established policies assuring that medical records of current enrollees and enrollees who leave the HMO plan are completed, promptly filed, and retained in safekeeping according to acceptable professional practices and State statutes.

G. When the HMO provides services directly to its enrollees at several locations, it shall ensure, through the coordination of medical records and the use of other appropriate operating procedures, that the services it furnishes at those various locations are organized in this manner as to facilitate continuity of care. A central patient record keeping system shall be maintained as required by the Department.

H. The HMO shall designate a member of the staff qualified by reason of training or experience, or both, who is responsible for the implementation of medical record policies and for the maintenance of the medical record system.