The NewYork Presbyterian Community Health Plan believes that complete and well - documented medical records are essential to effective and confidential patient care. In general, medical records should be well organized and contain only one member record per chart. Medical records should be kept in a secure and confidential area and must be available to the practitioner during patient visits. To assist our practitioners in assuring that their records meet our requirements, the standards for medical record documentation are listed below:

• Each and every page in the medical record should contain the patient's name or ID number.
• Personal/biographical data should include date of birth, gender, address & home telephone number and be updated at least annually.
• All entries in the medical record should be dated.
• All entries in the medical record must be legible.
• All entries in the medical record should contain author identification.
• Significant illnesses and medical conditions must be indicated on the problem list.
• Medication allergies & adverse reactions should be prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this must be appropriately noted in the record.
• Past medical history (for patients seen 3 or more times) should include serious accidents, operations and illnesses.
• There should be appropriate notations concerning the use of cigarettes.
• Each visit should contain appropriate subjective and objective information pertinent to the patient's presenting complaints.
• A complete initial physical exam should be recorded in the medical record and be repeated annually.
• Appropriate laboratory and other studies are ordered and completed.
• Working diagnoses should be noted to be consistent with findings.
• Treatment plans should be consistent with diagnosis.
• Progress notes should have a notation regarding follow-up care, calls or visits.
• Unresolved problems from previous office visits should be addressed at subsequent visits.
• There should be evidence of appropriate use of consultants.
• If consultation is requested, there should be a note from the consultant in the record.
• Consultant(s), lab(s), and imaging report(s) filed in the chart must acknowledged by the PCP either in the notes or by initialing, to signify review.
• Abnormal lab(s)/imaging study results must have an explicit notation in the record of follow-up plans.
• An appropriate immunization history must be noted in the record for both adults and children.
• There should be evidence of mental health/substance abuse screening during the most recent complete physical exam (new patient visit or annual follow-up).
• There should be evidence of screening for domestic violence during the most recent complete physical exam (new patient visit or annual follow-up).
• As applicable, there should be evidence of compliance with public health reporting requirements relating to communicable disease.
• There should be evidence of PCP review and follow-up of ER visit(s) and/or hospitalization(s).

In the event of questions regarding these standards please contact the Provider Services or Medical Management Departments.