CSHCN 2008 >24.2.1 General Medical Record Documentation Requirements

To receive reimbursement, the provider must document the following information in the client's medical record:

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Any pertinent information about the client's condition that supports the need for the service.

Note: If a provider bills for an office visit, the client's medical record must contain documentation for that date of service about the client's complaint, findings, and any physician orders. If the visit is a follow-up office visit, the client's progress relating to the previous condition must be documented for the date of service billed. If billing for a hospital visit, whether it is a routine hospital visit or other type of hospital visit, documentation of that visit must be part of the client's medical record and must be written in the physician's orders or the client's progress notes.

The TMHP-CSHCN Services Program routinely performs a retrospective review of all providers. This review may include comparing services billed to the client's clinical record. The following requirements are general requirements for all providers. Any mandatory requirement not present in the client's medical record subjects the associated services to recoupment.

Note: This list is not all-inclusive. Additional and more specific requirements may apply to special services areas.


Requirement	Mandatory/Desirable
All entries are legible to individuals other than the author, dated (month, day, and year), and signed by the performing provider.	Mandatory
Each page of the medical record documents the client's name and CSHCN Services Program identification number.	Mandatory
Allergies and adverse reactions (including immunization reactions) are prominently noted in the record.	Mandatory
The selection of E/M codes (levels of service) is supported by the client's clinical record documentation. The American Medical Association's (AMA's) Current Procedural Terminology (CPT) descriptors of key/contributory components with level of service descriptions are used to evaluate the selection of levels of service.	Mandatory
Necessary follow-up visits specify the time of return by at least the week or month.	Mandatory
The history and physical documents the presenting complaint with appropriate subjective and objective information, e.g., medical and surgical history, current medications and supplements, family history, social history, diet, pertinent physical examination measurements and findings, etc.	Mandatory
The services provided are clearly documented in the medical record with all pertinent information about the client's condition to substantiate the need for the services.	Mandatory
Medically necessary diagnostic lab and X-ray results are included in the medical record and abnormal findings have an explicit notation of follow-up plans.	Mandatory
Unresolved problems are noted in the record.	Mandatory
Immunizations are noted in the record as complete or up-to-date.	Mandatory
Personal data includes address, employer, home/work telephone numbers, sex, marital status, and emergency contacts.	Desirable