The following medical record standards apply to each enrollee’s record and will be used as a guide for the periodic on-site record reviews:

• Each record must contain identifying information on the enrollee, including name, enrollee identification number (Medicaid #), date of birth and sex; and legal guardianship (if any).
• Each record must contain a summary of significant surgical procedures, past and current diagnosis or problems, allergies, untoward reactions to drugs and current medications.
• All records must contain all services provided by providers; such services must include, but not necessarily be limited to, family planning services, preventive services and services for the treatment of sexually transmitted diseases.
• All records must contain documentation of referral services (including Health & Wellness Program if applicable)
• Each record must be legible and maintained in detail.
• Each record must contain an immunization history.
• Each record must contain information on smoking/ETOH (ethyl alcohol)/substance abuse.
• Each record must contain a record of emergency care and hospital discharge with appropriate medically indicated follow up.
• All records must reflect the primary language spoken by the enrollee and translation needs of the enrollee.
• All records must identify enrollees needing communication assistance in the delivery of health care services.
• All entries in each record must be dated and signed by appropriate part.
• All entries in each record must indicate the chief complaint or purpose of the visit; the objective findings of practitioner, diagnosis, or medical impression.
• All entries in each record must indicate studies ordered, for example: lab, x-ray, EKG, and referral reports.
• All entries in each record must indicate therapies administered and prescribed.
• All entries in each record must include the name and profession of practitioner rendering services, for example: M.D., D.O., and O.D., including signature or initials of practitioner.
• All entries in each record must include the disposition, recommendations, instructions to the patient, evidence of informed consent including risk and adverse outcome, whether there was follow-up, and outcome of services.
• Records must contain copy of any consent or attestation form used or the court order for prescribed psychotherapeutic medication for a child under the age of thirteen (13).
• Tout dosye dwe gen ladan dokiman ki te anwole a bay enfòmasyon ekri ladan l 'dwa anwole nan konsènan direktiv avanse (enstriksyon ekri pou k ap viv pral oswa pouvwa nan avoka), ak si wi ou non te anwole a egzekite yon direktiv avanse. Founisè a pa dwe, kòm yon kondisyon pou tretman, mande pou anwole a al touye oswa renonse yon direktiv avanse an akò avèk Seksyon 765,110, FS Tout dosye dwe gen ladan kopi nenpòt direktiv davans egzekite pa anwole nan (ki gen laj 18 ak pi gran ki gen ladan timoun minè emansipe / pou ki enskri ki poko gen 18 oswa ou pa emansipe - dokiman sou ofri / diskisyon ak paran / gadyen).
• Tout dosye dwe gen ladan Fòm Evalyasyon Risk Sante yon lè yon moun tounen pa anwole a e voye l nan founisè a.
• Tout dosye dwe gen ladan dokiman nan konklizyon enpòtan ak konsèy medikal bay anwole nan moun, pa telefòn, sou entènèt oswa bay apre-èdtan.
• Albòm nan anwole trete yon lòt kote oswa transfere nan yon lòt founisè swen sante yo prezan.
• Tout dosye dwe gen ladan yon eksplikasyon tou kout sou itilize nan telemedsin nan chak nòt pwogrè; dokiman nan ekipman telemedsin itilize pou sèvis sa yo an patikilye kouvri bay; ak yon deklarasyon ki siyen soti nan anwole a oswa reprezantan anwole nan ki endike chwa yo resevwa sèvis nan telemedsin (Deklarasyon sa a ka bezwen pou yon peryòd seri tretman oswa vizit yon sèl-fwa, jan sa aplikab nan sèvis la (yo) bay), pou sèvis yo ofri nan telemedsin. (Kounye a pa aplikab)

dosye sante konpòtman dwe gen ladan - pou chak sèvis yo ofri, idantifikasyon klè tankou nan:

• doktè a oswa lòt founisè sèvis
• Dat la nan sèvis
• inite yo nan sèvis yo ofri
• Ki kalite sèvis ki ofri