[Insert Name of Center]



TemplatePolicy and ProcedureRegarding Contents of Health RecordPolicyThe center and its licensed physicians/providers shall maintain an adequate health record for each patient that is complete, contemporaneous and legible. ProcedureMedical record documentation concerning services provided to patients, and patient clinical assessment and management shall be consistent with applicable federal and state laws and regulations, Centers for Medicare and Medicaid Services (CMS) guidelines, accepted professional standards, and other applicable reimbursement requirements.Coding for purposes of reimbursement or tracking shall be performed consistent with accepted professional standards to most accurately reflect the nature of services provided.Certifications by center staff are based upon the documentation in the medical records.Staff shall receive orientation and training on proper documentation and coding, and medical record management.Audits are conducted on medical records to confirm quality, medical necessity and appropriateness of clinical services, and proper use of coding. Staff performing the audits are trained in medical record review and the accepted professional standards. Medical record audit reports may be performed as under the center CPI Program and are reported to the CPI Officer and to the Executive Director.An “adequate medical record” should meet the following standards: The documentation of each patient encounter should include identification and social data; reason for the encounter and relevant history, physical examination findings and prior diagnostic test results; a brief summary of the episode, diagnosis, treatment plan (or options) and instructions to the patient; the date and legible identity of the observer. Past and present diagnoses should be accessible to the treating and/or consulting physician.The rationale for and results of diagnostic and other ancillary services should be included in the medical record. The patient’s progress, including response to treatment, change in diagnosis, and patient’s non-compliance should be documented. Relevant risk factors should be identified. The written plan for care should include when appropriate: treatments and medications (prescriptions and samples) specifying amount, frequency, number of refills, and dosage; any referrals and consultations; patient/family education; and, specific instructions for follow up. Any written consents for treatment or surgery requested from the patient/family by the physician.Billing codes, including CPT and ICD-9-CM codes, as reported on health insurance claim forms or billing statements, which should be supported by the documentation in the medical record.Clear indications of the time and date of the amendment, supplementation, change, or correction of a medical record not made contemporaneously with the act or observation. Records received from another physician or health care provider involved in the care or treatment of the patient shall be maintained as part of the patient’s medical record.Note: the Texas Medical Board acknowledges that the nature and amount of physician work and documentation varies by type of services, place of service and the patient’s status. Paragraphs?A – J, above may be modified to account for these variable circumstances in providing medical care.Documentation and CodingProviders and designated staff shall document in the medical record according to applicable professional standards. The documentation must be sufficient to provide a baseline for continued health care services and must provide support for coding and billing for the encounter. Entries shall be:??Accurately dated;Made by authorized staff;Signed by the responsible physician/provider with title/position; andDocumented in black or blue ink/font.Any section or space that is “not applicable” is marked “N/A” or a single line marked through rather than being left blank.All transcribed reports include the date of dictation and the date of transcription. Transcribed reports must be signed by the person dictating to verify accuracy.In certain instances, the healthcare providers will designate the billing code on the encounter form. The documentation in the medical record must support any billing codes in relation to level of visit and services provided.In other instances the billing codes are assigned by trained coding staff using current coding sets and standards. The codes assigned must be supported by the documentation in the medical record.When the encounter form is forwarded to the center’s billing office, the billing and coding staff shall confirm the accurate codes prior to submitting the bill. The center’s billing and coding staff shall clarify any questions with the provider and/or Medical Director prior to submitting the statement.The center’s billing and coding staff shall confirm that the appropriate information is available for the standard billing transaction consistent with Health Insurance Portability and Accountability Act (HIPAA) standards.CorrectionsIf a correction is to be made in the medical record the following protocol should be enabled by your electronic health record:??Make a single line through the incorrect entry.Indicate “error” next to the incorrect entry.Date and sign your initials to the entry. If appropriate, make corrections on records in current sequence. If a note is added to the record at a future time, state the exact date the entry is made, in addition to the date the entry refers to. Date and sign corrected entry.At no time should anything be deleted from a medical record without a record of that deletion being kept. Pages of the medical record may not be removed and recopied to make corrections.Late EntriesAddendums or late entries are used as a mechanism to add information to the medical record after the record has been closed or completed. The addendum or late entry is signed and dated (electronic signature and date are acceptable) by the physician or other healthcare provider. Late entries should be avoided unless necessary to correct or clarify the patient’s medical record.Patient Amendment or AddendumAny alterations or amendments requested by the patient are recorded as an addendum without changing the original entry consistent with HIPAA privacy standards as stated in the center’s Notice of Privacy Practices. (See HIPAA policies and procedures).AuthenticationThe center is responsible for ensuring that appropriate provider signatures (electronic are acceptable) are used when entering information into the medical record. The center will ensure:??Only individuals specified in the center’s policies and procedures may make entries in the medical record. All entries in the medical record must be dated and authenticated, and a method established to identify the author. The identification may include written signatures, initials, computer key, or other code as identified in the center policy and procedure; the center electronic health record system should offer each staff member with access to the record a different login, then mark their work in the record as authored by them;When rubber stamps or electronic signatures are authorized, the individual whose signature the stamp represents shall place in the administrative offices of the center a signed statement to the effect that he/she is the only one who has the stamp and uses it. There shall be no delegation to another individual. A list of computer or other codes and written signatures must be readily available and maintained under adequate safeguards. There shall be sanctions for improper or unauthorized use of stamp, computer key, or other code signatures;The parts of the medical record that are the responsibility of the physician must be authenticated by that physician. When non-physicians have been approved for such duties as taking medical histories or documenting aspects of physician examination, such information shall be appropriately authenticated by the responsible physician. Any entries in the medical record by staff or non-physicians that require counter signing by a supervisory or attending medical staff member in accordance with the center’s policies and procedures;There must be a specific action by the individual creating the entry in the medical record to indicate that the entry is verified and accurate. The center will adopt any of the following authentication systems:??Computerized systems that require the physician to review the document on-line and indicate that it has been approved by entering a computer code. A system in which the physician signs off against a list of entries that must be verified in the individual record. A mail system in which transcripts are sent to the physician for review, then he/she signs and returns a postcard identifying the record and verifying their accuracy. Note: a system of auto-authentication in which a physician or other practitioner authenticates a report before transcription is not acceptable. There must be a method of determining that the practitioner did, in fact, authenticate the document after it was transcribed. Unsigned dictation is not acceptable. ................
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