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and classification of the person making the entry. • Members’ medical records shall be stored to ensure protection against loss, destruction, or unauthorized use. • Members’ medical records shall be filed in an easily accessible manner in the PCP’s office or primary care clinic. • The medical record must reflect all aspects of the member’s care, including ancillary services, and at a minimum include the following: ƈ Member identification on each page; personal/biographical data in the record; ƈ The VHP member’s preferred language (if other than English) and disability access needs prominently noted in the record, as well as the request or refusal of language/ interpretation/disability access services; ƈ For member visits, the entries shall include at a minimum, the subjective complaints, the objective findings, assessment and the plan for diagnosis and treatment (SOAP notes); ƈ The record shall contain a problem list, a complete record of immunizations, medical maintenance and preventive services rendered; ƈ Allergies and adverse reactions must be prominently noted in the record; ƈ All informed consent documentation, including for human sterilization consent procedures; ƈ All reports of emergency care provided (directly by the provider or through an emergency room) and the discharge summaries for all hospital admissions; ƈ Consultations, referrals, specialist consultations, pathology, and laboratory reports; ƈ Any abnormal results shall have an explicit notation in the record; and ƈ For medical records of adults, documentation of whether the member has been informed of their rights to make decisions concerning medical care; to have an Advance Directive; and whether an Advance Directive or a Durable Power of Attorney for Medical Care has been executed. All clinical requirements for medical records are set forth in VHP’s Medical Records policy, which is available by contacting Provider Relations at: providerrelations@vhp.sccgov.org, or to VHP in writing at:
Valley Health Plan Attn: Provider Relations 2480 N. First Street, Suite 160 San Jose, CA 95131
The clinical medical records requirements policy is also provided in the provider orientation package.
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2021 / Provider Manual
CH 8: Facility Site, Physical Accessibility & Medical Record Review
