Documentation and confidentiality of medical records, Preferred Care Partners - 2022 UnitedHealthcare Administrative Guide

You are required to protect records, correspondence and discussions regarding the member.

You must keep a medical records system that:

  • Follows professional standards.
  • Allows quick access of information.
  • Provides legible information that is correctly documented and available to appropriate health care providers.
  • Maintains confidentiality.

Have our member sign a Medical Record Release Form as a part of their medical record. Contact Network Management Services, 1-877-670-8432, to request a copy of this form. The member should sign a Refusal Form when declining a preventative screening referral.

Follow these confidentiality guidelines:

  • Records that contain medical, clinical, social, financial or other data on a patient are treated as confidential. They must be protected against loss, tampering, alteration, destruction, or inadvertent disclosure.
  • Release of information from your office requires that you have the patient sign a Medical Record Release Form that is retained in the medical record.
  • Release of records is in accordance with state and federal laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  • Records containing information on mental health services, substance use, or potential chronic medical conditions that may affect the member’s plan benefits are subject to additional specific waivers for release and confidentiality.

Exemption from release requirements

HIPAA regulations allow us to give PHI to government programs without member permission. This is given to determine member eligibility.

Medical records requirements

You must ensure your medical records meet the standards described in this section. The following are expanded descriptions of these requirements:

Patient Identifiers: Consist of the patient name and a second unique identifier; they should appear on each page of the medical record.

Advance Directives: Provide the member with advance directive information and encourage them to retain a copy for their personal records. Document this conversation at least once in the member’s medical record.

Biographical Information: Include the member’s name, date of birth, address, home and work phone numbers, marital status, sex, primary language spoken, name and phone number of emergency contact, appropriate consent forms and guardianship information, if relevant.

Signatures: For paper medical records, have all entries dated and signed or initialed by the author. Author identification may be a handwritten signature or initials followed by the title (e.g., MD, DO, PA, ARNP, RN, LPN, MA or OM). There must be a written policy requiring, and evidence of, physician co-signature for entries made by those other than a licensed physician (e.g., MD, DO). Electronic signatures are acceptable for electronic medical records.

Family History: Document the family medical history no later than the first visit.

Past Medical History: Include a detailed medical, surgical and social history.

Immunizations: Include the date the vaccine was administered, the manufacturer and lot number and the name and title of the person administering the vaccine. At a minimum, you must have members’ vaccination history.

Medication List: List the member’s current medications, with start and end dates, if applicable. Reconcile within 30 days after inpatient admissions.

Referral Documentation: If a referral was made to a specialist, file the consultation report in the medical record. Include documentation that the physician has discussed abnormal results with the member, along with recommendations.

Chart Organization: Maintain a uniform medical record system of clinical recording and reporting with respect to services, which includes separate sections for progress notes and the results of diagnostic tests.

Preventive Screenings: Promote the appropriate use of age- or gender-specific preventive health services for members to achieve a positive effect on the member’s health and better medical outcomes.

Required Encounter Documentation: For every visit, document the following:

  • Date
  • Chief complaint or purpose
  • Objective findings
  • Diagnosis or medical impression
  • Studies ordered (lab, X-ray, etc.)
  • Therapies administered or ordered
  • Education provided; disposition, recommendations or instructions to the member and evidence of whether there was follow- up
  • Outcome of services

You must document that a written policy regarding follow-up care and written procedures for recording results of studies and therapies and appropriate follow-up is in place.

We recommend that medical records include copies of care plans whenever you provide home health or skilled nursing services.