PARKLAND HEALTHfirst - Parkland Community Health Plan, Inc.

Medical Record Standards
The medical records reflect all aspects of patient care, including ancillary services. These standards shall, at a
minimum, include requirements for:
1) Patient identification information. Each page or electronic file in the record contains the patient's name or
patient ID number.
2) The use of electronic medical records must conform to the requirements of the Health Insurance Portability
and Accountability Act (HIPAA) and other federal and state laws.
3) Personal/biographical data, including: age; sex; address; employer; home and work phone numbers; and
marital status.
4) All entries are dated and author identified.
5) The record is legible to someone other than the writer. A second reviewer should evaluate any record judged
illegible by one physician reviewer.
6) Allergies. Medication allergies and adverse reactions are prominently noted on the record. Absence of
allergies (no known allergies – NKA) is noted in an easily recognizable location.
7) Past Medical History (for patients seen three or more times). Past medical history is easily identified
including serious accidents, operations, and illnesses. For children, past medical history relates to prenatal
care and birth.
8) Immunizations. For pediatric records there is a completed immunization record or a notation of prior
immunizations, including vaccines and dates given, when possible.
9) Diagnostic Information.
10) Medication Information (includes medication information/instruction to member).
11) Identification of Current Problems. Significant illnesses, medical and behavioral health conditions, and
health maintenance concerns are identified in the medical record.
12) Member is provided basic teaching/instructions regarding physical and/or behavioral health condition.
13) Smoking/Alcohol/Substance Abuse. Notation concerning cigarettes and alcohol use and substance abuse is
present. Abbreviations and symbols may be appropriate.
14) Consultations, Referrals and Specialist Reports. Notes from any referrals and consultations are in the record.
Consultation, lab, and X-ray reports filed in the chart have the ordering doctor's initials or other
documentation signifying review. Consultation and any abnormal lab and imaging study results have an
explicit notation in the record of follow-up plans. Referrals to out-of-network providers (non-contracted
providers) must include justification to Parkland KIDSfirst or Parkland CHIP Perinate Newborn. (See Out-of-
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Network Referrals on page 81)
15) All emergency care provided (directly by the contracted provider or through an emergency room) and the
hospital discharge summaries for all hospital admissions while the patient is enrolled.
16) Hospital Discharge Summaries. Discharge summaries are included as part of the medical record for: (1) all
hospital admissions, which occur while the patient is enrolled with the Contractor, and two (2) prior
admissions as necessary. Prior admissions as necessary pertain to admissions, which may have occurred
before member being enrolled with the Contractor, and are pertinent to the member’s current medical