Humana Military may review your medical records on a random basis to evaluate patterns of care and compliance with performance standards. Policies and procedures should be in place to help ensure that a beneficiary’s medical record is kept organized and confidential. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services.
The following guidelines will assist you in documenting medical and surgical care in each patient’s record:
Notes in the patient’s medical record must be legible to someone other than the writer.
Make sure the beneficiary’s name or ID number is on every page in his or her record.
Include important personal/biographical data: address, employer, home and work telephone numbers, and marital status.
Make sure all entries in the medical record contain the author’s ID, which may be a handwritten signature, unique electronic identifier, or initials.
Date all entries.
Indicate significant illnesses on a problem list
Note—prominently—all medication allergies and adverse reactions, if any.
Make the patient’s medical history (for beneficiaries seen three or more times) easily identifiable, and include serious accidents, operations, and illnesses.
For children and adolescents (up to age 18), note prenatal care, birth, operations, and childhood illnesses within the medical history.
For beneficiaries age 14 and older who have been seen three or more times, note information concerning use/abuse of cigarettes, alcohol, and controlled substances.
Histories and physicals should contain appropriate subjective and objective information for presenting complaints.
Order laboratory and other studies as appropriate, and document them.
Ensure working diagnoses are consistent with findings, and that treatment plans are consistent with diagnoses.
When filling out encounter forms or notes, include a notation, when indicated, regarding follow-up care, calls, or visits. The specific time of return should be noted in weeks, months, or “as needed.”
Address unresolved problems from previous office visits in subsequent visits.
Reviews should be conducted for underutilization or overutilization of consultants.
Enter consultation notes/results on the chart.
Make sure the ordering practitioner initials all filed consultation, laboratory, and imaging reports to signify review. Review and signature by professionals other than the ordering practitioner do not meet this requirement. If the reports are presented electronically or by some other method, document the ordering practitioner’s review.
Consultation, abnormal laboratory, and imaging study results should include explicit notations of follow-up.
Use individual records to demonstrate whether the care was needed and if it satisfactorily met the beneficiary’s needs.
Immunization records for children must be up to date, and history must be made in the medical records for adults.
Include evidence that preventive screening and services were offered and accepted or rejected in accordance with the office’s practice guidelines.
In cases of unusual deaths, or in deaths of medical-legal and educational interest, document any request (consent or refusal) for an autopsy.
When documenting injections, include:
Name of drug
Lot number
Time of administration
Dosage
Route of administration
Site of injection
Signature or initials of individual administering the medication
For immunizations: lot number, manufacturer, verification that the Vaccine Information Statement was given to the patient or parent/guardian, and the name and address of the health care provider administering the vaccine.
