2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Care Coordinationor when the member changes primary medical,dental, or behavioral health practitioners. Theinformation forwarded shall include but is notlimited to the following:A list of the member’s principal physical andbehavioral health problems, as applicableA list of the member’s current medications,dosage amounts, and frequencyThe member’s preventive health serviceshistoryEarly and Periodic Screening, Diagnosis, andTreatment (EPSDT) screening results (forPresbyterian Centennial Care members underage 21)Other information necessary to ensurecontinuity of carePractitioners shall ensure that they have policies orplans in place for medical record authorized accessand coordination in the event that they areincapacitated in some way.Practitioners and providers shall make any and allmember medical records available to PHP,Presbyterian Insurance Company, Inc., the NewMexico Superintendent of Insurance, the CMS, theNew Mexico Human Services Department (HSD),and other state and federal regulatory agencies ortheir agents, for the purpose of quality review,annual NCQA HEDIS ® audits, and for investigationof member grievances or complaints.Minimum Medical Record StandardsPresbyterian has adopted medical recordsstandards from the NCQA, the NMAC, Title 8,Section 305.8.17, and the Medicare Managed CareManual. The following standards apply to bothphysical and behavioral health unless otherwisenoted:1. ConfidentialityPatient records must be maintained and managedin a confidential manner in accordance with allapplicable state and federal laws, including, but notlimited to, the privacy and security rules asprovided for under HIPAA.2. Legibility and Provider IdentificationPatient records must be maintained in atimely, legible, current, detailed, andorganized manner to permit effective andconfidential patient care and quality review.The patient record must be legible to personsother than the writer.3. EntriesAll entries must be dated and include date of entryand date of encounter. The entries, includingdictation, must be identified by the author andauthenticated by his or her entry. Authenticationmay include signature or initials verifying that thereport is complete and accurate. Patient recordnotes generated or stored electronically bycomputer are considered authenticated if there is ademonstrated password-protected entry with atime-limited edit capability.4. Organization/Patient IdentificationPatient records must be organized systematicallyand uniformly. Paper documentation must be firmlysecured or attached in the patient record/medical6-212014 Practitioner and Provider Manual - Ver. 3