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R Record Review
This Chapter Includes:
1. Facility Site Review Process 2. Conducting the Site Review 3. Site Review Tools
4. Facility Site Review Tool/Guidelines 5. Medical Record Review Tool/Guidelines
6. Medical Record Requirements and Review 7. Medical Record Regulatory Requirements 8. Clinical Requirements for Medical Records 9. Medical Records Release
10.Medical Records Transfer for New Members
11. Medical Record Reviews
Alert
Alert draws attention to critical information that has changed this year.
Contact
Contact information on who to contact for assistance.
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Facility Site Review Process
The facility site review is a comprehensive evaluation of a provider’s facility, administration, and medical records maintenance to ensure that the facility meets certain safety, accessibility, and security standards pursuant to state and federal regulations. The review of PCP sites is required for all VHP contracted PCPs and VHP reserves the rights to adopt additional requirements.
The overall facility site review process has three components: 1. Facility site review (FSR); 2. Physical accessibility review survey; and 3. Medical records review (MRR).
Providers must have a site review conducted prior to being credentialed by VHP. Thereafter, providers will be included in a sampling audit, which is based on the three-year FSR requirement. All providers must make their offices available for a physical accessibly review, FSR, and/or MRR audit. Provider participation in reviews and audits is mandatory. VHP will collaboratively work with providers to coordinate visits and minimize the impact of reviews/audits on provider office operations as well as to ensure that VHP meets regulatory and contractual requirements.
Conducting the Site Review
A VHP Representative from Provider Relations or Quality Management departments will contact providers to schedule an appointment date and time for a site review and provide a confirmation letter with an explanation of the review process and required documentation.
During an in-person site review, a VHP reviewer will: • Lead the pre-review conference with the provider or office manager to provide an overview of the process and answer any questions; • Conduct the site review; and • Document any deficiencies.
Following the site review, the VHP reviewer will confer with the provider or office manager to: • Discuss the results of the review and explain any required corrective actions; • Provide a results letter and corrective action plan to the office manager or provider, when applicable; • Educate the provider or office staff about the standards and policies; and • Schedule a follow-up review for any corrective actions identified.
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PCP and primary care clinic site review results must be 90% or greater with all critical elements “met” to pass. Scores below 90% or with any critical element “not met” will require a corrective action plan (CAP). A written CAP from the PCP or primary care clinic is required within 30 calendar days of the date on the results letter received from VHP. The CAP should be sent to the VHP reviewers who conducted the facility site review.
Site Review Tools
See the Appendix for Site Review Tools Examples
Facility Site Review Tool/Guidelines
If you would like to review the facility site review survey tool which includes the physical accessible review component, scoring and guidelines, please use the following links:
• FSR Tool. https://www.valleyhealthplan.org/sites/p/fr/Documents/Provider-Forms/Behavioral-Health-
Office-Audit-Tool.pdf • Medical Clinic/Office tool https://www.valleyhealthplan.org/sites/p/fr/Documents/Provider-Forms/Medical-Clinic-
Office-Audit-Tool.pdf
Medical Record Review Tool/Guidelines
If you would like to see how the medical record review will be audited, scored and the guidelines, use the following link: https://www.valleyhealthplan.org/sites/p/fr/Documents/Provider-Forms/Medical-
Record-Audit-Tool.pdf
Medical Record Requirements and Review
VHP reviews medical records for format, legal protocols, and documented evidence of the provision of preventive care, care coordination, and continuity of care services. Incomplete records or lack of documentation implies that there was a gap or failure to provide care. The medical record provides legal proof that the member received care and therefore must reflect all aspects of a member’s care and ancillary services, including but not limited to the following:
Medical Record Regulatory Requirements
• A record shall be permanent, either electronic, typewritten or legibly written in ink and shall be kept for each unique VHP member accepted for treatment. • All medical records of discharged VHP members shall be completed within 30 days following termination of each episode of treatment and such records shall be kept for a minimum of seven
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years, except for minors whose records shall be kept at least until one year after the minor has reached the age of 18, but in no case less than seven years. This includes all records, results of diagnostics including exposed x-ray film. All required records, either originals or accurate reproductions thereof, shall be maintained in such form as to be in English, legible and readily available upon the request of the provider, the primary care clinic or any authorized officer, agent or employee of either, or any person authorized by law to make such request. Information contained in the medical records shall be confidential and shall be disclosed only to authorized persons in accordance with federal, state, and local laws. The medical record shall be the property of the provider and shall be maintained for the benefit of the member, medical care team and primary care clinic and shall not be removed from the VHP provider’s office or primary care clinic, except for storage purposes after termination of services. Providers must delegate an individual to be responsible for the securing and maintaining medical records at each site. If a provider ceases operation, arrangements shall be made for the safe preservation of VHP’s members’ medical records. The provider who ceases operation must notify VHP at least 48 hours before cessation of operation 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
If the ownership of a provider’s practice changes, both the licensee and the applicant for the new license shall, prior to the change of ownership, provide VHP with written documentation. The written documentation can be emailed to: providerrelations@vhp.sccgov.org or mailed to Valley Health Plan 2480 N. First Street, Suite 160 San Jose, CA 95131. The written documentation shall state the following: ƈ The new licensee shall have custody of VHP’s members’ medical records and these records shall be available to the former licensee, the new licensee, and other authorized persons; or ƈ The current licensee has made other arrangements for the safe preservation and the location of the members’ medical records, and that they are available to both the new and former licensees and other authorized persons.
Clinical Requirements for Medical Records
• All medical record entries shall be dated and be authenticated with the name, professional title,
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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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Medical Records Release
All VHP member medical records shall be confidential and shall not be released without the written authorization of the member or a member’s legal guardian or authorized representative. When the release of medical records is appropriate, the extent of that release shall be based upon medical necessity or on a need to know basis. Providers and community mental health programs must obtain written consent from the member to release information to coordinate care regarding primary care and mental health services or substance use disorder services or both.
Medical Records Transfer for New Members
When a member changes their PCP or primary care clinic, upon request, his or her medical records or copies of medical records must be forwarded to the newly assigned PCP or primary care clinic within ten business days from receipt of request or prior to the next scheduled appointment to the new PCP, whichever is earlier. All PCPs and primary care clinics are required to document in the VHP member’s medical record attempts to obtain historical medical records for all newly assigned VHP members. If the member or member’s guardian is unable to remember where they obtained medical care, or they are unable to provide addresses of the previous PCP or providers, then this should also be noted in the medical record.
Medical Record Reviews
VHP will conduct random medical record review audits as part of its Quality Assurance Program to monitor compliance with the medical record documentation standards and requirements. The coordination of care and services provided to members, including over/under utilization of specialists, as well as the outcome of such services, also may be assessed during a medical record audit. VHP will provide written notice prior to conducting a medical record review.
MRR audit results must be 90% or greater to pass. Scores below 90% will require a CAP. A written CAP from the provider is required within 30 calendar days of the date the results letter is received from VHP. The CAP should be sent to the VHP reviewer who conducted the MRR audit
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