WHA's Provider Network
Policies & Guidelines
Pharmacy Information
Clinical Resources
Health Promotion & Disease Management
Quality & Safety
Member & Provider Rights
Language/Assistance Program
Provider Communications
WHA's Medical Record Management Standards
Western Health Advantage has established medical record policies and procedures to ensure consistency
in practice and effective communication among providers to support the continuity and coordination of care
of WHA members. WHA's Quality Improvement Committee is responsible for oversight of these policies.
WHA delegates medical record management/health information management functions to its contracted medical
groups/IPAs and has established policies and procedures to address these functions including availability
of medical records, related privacy and confidentiality, and expected performance goals. WHA maintains
responsibility for oversight of these functions and assesses the delegate's compliance to the standards
through policy/procedure review, semi-annual reports submitted by the delegates, onsite visits and annual
review of medical record documentation.
Medical Record Requirements for Providers
Medical providers must have a secure and available system for managing the medical records for each member. This system may be either hard-copy (paper) or electronic. WHA's standards include:
Medical Record Management Standards
| 1. | Medical Group/IPA practitioners must have written processes or policies/procedures addressing the management of medical record systems/documentation standards/medical record keeping practices at practitioner sites that include specifics related to the following standards. These documents are made available to the health plan, regulatory and accreditation agencies upon request. |
| 2. | Medical Group/IPA practitioners must maintain an individual hard-copy or electronic medical record (EMR) for each member. Electronic medical records or member data must:
|
| 3. | The medical record keeping system must ensure:
|
| 4. | Hard-copy and electronic medical records that are in use, are maintained in such a manner that the contents cannot be viewed by persons unauthorized to access such records. |
| 5. | Medical Group/IPA practitioners and their staff have a documented system for tracking hard-copy medical records when a record is removed from the centralized filing system. (Mental health and substance abuse records may be filed separately from the member's main medical record.) |
| 6. | Medical Group/IPA practitioners and their staff have a documented system in place to follow-up on referrals, procedures or tests cancelled for cause by the member, and laboratory, x-ray, consultation reports or other information that hasn't been reviewed. |
| 7. | Medical Group/IPA practitioners and their staff have a documented system in place to ensure that inactive records and purged hardcopy and electronic medical data are archived in a manner that meets federal and state requirements. These records remain accessible for a period of time consistent with those regulations (currently five years) and to age of majority for minors. |
| 8. | Medical Group/IPA practitioners and their staff have a documented system in place to obtain Consent for Treatment given by the member, parent, or guardian at the initial office visit by signing a Consent to Treatment form filed in the member's medical record. Any special consent forms signed must be present in the member's medical record. |
| 9. | Release of hard-copy or electronic medical records are provided only by Medical Record Department or Health Information Management staff or personnel with responsibility for such release of information. There is documented evidence that staff have received periodic training regarding HIPAA Privacy Regulations and maintaining confidentiality of member information. |
| 10. | Member protected health information is released in accordance with the HIPAA Privacy regulations and any other applicable federal or state regulations. Authorization forms permitting the release of medical records specify all of the items set forth in the HIPAA regulations (including the type of information requested, name of requestor, name/ID/DOB of member, dated signature of member or authorized representative, date of request, and date of release). Release of information in response to a court order or other legal process is reported to the member when required by HIPAA. |
Medical Record Documentation Standards
WHA has established seven standards for practitioner medical record documentation in the ambulatory setting.
| 1. | Patient name or ID present on each page. |
| 2. | Consultations are documented as appropriate. |
| 3. | Medication allergies and adverse drug reactions are present. |
| 4. | Clinical findings and evaluation are present every visit, including: diagnoses, appropriate history & physical findings. |
| 5. | Pathology, laboratory and other reports are recorded. |
| 6. | Provider is identifiable for every entry. |
| 7. | Case management and/or multidisciplinary team notes are present if applicable. |
Monitoring of Practitioner Documentation
WHA conducts oversight reviews of practitioner documentation of the seven standards as required by regulatory requirements for compliance oversight. WHA's methodology established Primacy Care Practitioners (PCP) with 50 or more assigned members will be reviewed at least once every three years for each Medical Group/IPA. A sample size of 5 to 20 medical records per practitioner will be reviewed depending on the number of assigned members per PCP. The study is conducted annually by Registered Nurses in WHA's Clinical Quality Improvement department. Results are reported to WHA's Quality Improvement Committee and feedback is provided to providers and each medical group for process improvement.