7.5.11.2 Medical Records StandardsA PCCM provider is required to maintain comprehensive and accurate medical records to ensure quality and continuity of care. Each provider must maintain and make available medical records in accordance with the applicable provider agreement. Content of Medical Record Each patient's medical record must include patient identification information, progress notes, and laboratory, referral, and consultation notes. Data to be maintained includes:
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• Refer to: "General Medical Record Documentation Requirements" . In addition, PCCM providers performing THSteps comprehensive medical check ups must document all components of the check up. These documentation requirements are detailed in "Documentation of Completed Check Ups" . Upon request, a provider will supply PCCM staff with copies of client medical records, as outlined in the provider agreement, for implementation of utilization management, quality improvement, and grievance programs. Confidentiality of Medical Records The relationship and all communication between physician and patient are privileged. Accordingly, the medical record containing information about the relationship is confidential. A physician's code of ethics, as well as Texas and federal laws, protect against the disclosure of the contents of medical records to persons or agencies that are not properly authorized to receive such information. For a provider to release the contents of a patient's medical record to a third party, the patient must first authorize the disclosure by signing and dating an authorization form. If the record is for a deceased individual, the executor of the estate must authorize the release. PCCM's policy is to allow only medical personnel and health professionals who are directly involved in the delivery or evaluation of a patient's records to access the medical record. All requests for medical record information must be handled according to policy and law. An authorization from the patient for release of medical information is not required when the release is requested by and made to PCCM, TMHP, HHSC, the external quality review organization, or the Texas Attorney General's Medicaid Fraud Control Unit. Medical Records Audits PCCM Provider Relations staff performs a general medical record review of the primary care provider's practice as part of the credentialing and recredentialing process and as part of the quality improvement program. The "Primary Care Case Management (PCCM) Pre-Contractual/Recredentialing Site and Medical Record Evaluation" is used to evaluate provider medical records as part of the credentialing and recredentialing process. Medical record audit results are submitted to the Medical Director and, if necessary, to the Credentialing Committee for review. Depending upon review findings, the Credentialing Committee will assist the Medical Director in concluding the audit in one of three ways:
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• These recommendations apply to audits of an initial review of a provider as well as those of subsequent reviews. If a provider has been found to be marginally in compliance with requirements, he will be given training and education directed at correcting the deficiency. PCCM will establish a system to audit this provider every 60 days for a maximum of three follow-up audits:
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• Medical records may also be reviewed in conjunction with provider profiling to identify opportunities to improve care and services. Access and Availability Standards PCCM staff routinely evaluates and monitors provider compliance with scheduling requirements. These scheduling requirements are designed to enhance access to health services and to provide assurance of service availability based on the urgency of need:
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• Refer to: "Primary Care Provider Requirements and Information" . |
Patient identification information:
