Medical Record-Keeping

Our record-keeping standards are consistent with requirements outlined by the National Committee for Quality Assurance and incorporate Medicare & Medicaid Services (CMS) requirements. As part of these standards, please keep the following in mind as you update your medical records:

• Medical records should include the patient’s name and identification number on each page.
• Each entry in the medical record should be legible, signed with the clinician’s name and credentials, dated, and maintained in a consistent chronological order.
• Medical records should be easily and readily retrievable in a secure environment that protects participant confidentiality.
• Medical records should include documentation of all contacts regarding the individuals to whom you provide services.

For a full list of essential items to include in your medical records, please refer to the "Quality Management" section of our Medical Management Program Guide.

Medical Record Review Process

We annually audit selected medical records, and assess them against our medical record-keeping standards using a standardized audit tool. A detailed description of this audit tool can be found in the "Quality Management" section of our Medical Management Program Guide. Our staff reviewers have been administered training and Inter-reviewer Reliability tests. If your medical records do not meet the established criteria, we will notify you. Deficiencies must then be resolved within 90 days of notification.

Medical Record Review Findings for 2013

Overall medical record compliance improved to 95% in 2013, representing a continuing three year improvement trend (from 92.2% in 2010 and 95% in 2013). Each category of health care professional licensure exceeded the 80% goal. Three professionals in any category scored less than the 80% compliance goal in 2013. The items that were scored less than 80% included documentation of preventive health services and coordination of behavioral care with primary care physicians. Documentation of preventive health services, while still under goal, remained stable over the 2 year period, as did evidence for continuity and coordination of care with primary care physicians and other behavioral treatment health care professionals.

Actions Planned for 2014

Even though the overall results for 2013 met the established goal, opportunities remain for improvement in 2014. As a professional, you may wish to review your record-keeping to assure that you adequately document coordination of medical and behavioral care, as well as performance of a developmental history, as appropriate. Periodically, repeat and document the request for consent to communicate with other medical and behavioral professionals who are involved in treatment of individuals in your care. As individual needs and status changes, revisit the importance of continuity and coordination of care.

Our behavioral Medical Management Program Guide is available free for download. It lists expected items to be documented in the health care professional treatment record. If you have questions concerning medical record-keeping practices, or questions and suggestions about Cigna's Quality and Utilization Management Program, please contact your Professional Relations Representative. We welcome your input.