Medi-Cal Medical Record Documentation Standards

Medi-Cal providers are required to meet both Health Net and the Department of Health Care Services (DHCS) Medi-Cal medical record documentation standards. The following documentation guidelines must be followed and all of the elements must be included in the medical records of Medi-Cal members.

• Format - The primary language and linguistic service needs of non- or limited-English proficient (LEP) or hearing impaired persons, individual personal biographical information, emergency contact, and identification of the member's assigned primary care physician (PCP).
• The refusal or request of interpreter services by an LEP-speaking health plan member must be documented in the medical record. Providers are required to document in the medical record the refusal of qualified interpreter services and the preference of a health plan member to use a family, friend or minor as an interpreter.
• Documentation - Medical record entries and corrections must be documented in accordance with acceptable legal medical documentation standards; allergies, chronic problems, and ongoing and continuous medications must be documented in a consistent and prominent location; all signed consent forms and the ofference of advanced health care directive information and education to members 18 and older must be included.
  • Telephone advice - notation of the date of the call, time, details of the conversation, and signature and title of the staff member handling the call.
  • Urgent and emergency documentation - notation of the date, time, means of arrival, history of illness or accident, physical findings, diagnostic tests, treatment received, diagnostic impression, and discharge summaries.
• Coordination of care - Notation of missed appointments, follow-up care and outreach efforts, practitioner review of diagnostic tests and consultations, history of present illness, progress and resolution of unresolved problems at subsequent visits, and consistent diagnosis and treatment plans.
• Preventive care - All new Medi-Cal members must receive an Initial Health Appointment (IHA), which includes an age-appropriate history and physical examination within 120 days of enrollment.
  • Members may be seen initially during a visit for episodic care. Regardless of the reason for the initial visit, the PCP or other provider within the primary care setting, should conduct the IHA at the first health care contact and document the assessment in the medical record.
• Adult preventive care and anticipatory guidance, according to the United States Preventive Services Task Force (USPSTF) - Notation of periodic health evaluations, assessment of immunization status and the year of the immunization(s), tuberculosis screenings and testing, blood pressure and cholesterol screenings, Chlamydia screenings for sexually active females to age 25 or at risk, and mammograms and Pap tests for females.
• Pediatric preventive care and anticipatory guidance, according to the AAP - Notation of age-appropriate physical exams; immunizations specified and within AAP and Healthcare Effectiveness Data and Information Set (HEDIS^®) requirements; anticipatory guidance for age-appropriate levels; vision, hearing, lead, and tuberculosis screenings and testing; and nutrition and dental assessments.
• DHCS requires providers to document each member's need for Advisory Committee on Immunization Practices (ACIP)-recommended immunizations as part of all regular health visits and to report the administration of immunizations within 14 days.
  • Providers must enroll in and use the California Immunization Registry (CAIR) website at CAIRweb.org to report and track patient immunization records online.
• Perinatal preventive care - notation of prenatal care visits according to the most recent American Congress of Obstetrics and Gynecology (ACOG) standards, including a timely prenatal visit within the first trimester; initial and subsequent comprehensive prenatal assessments (ICA) and trimester reassessments; postpartum visit four to six weeks after delivery - this interval may be modified according to the needs of the member, such as HEDIS timelines of 21-56 days after delivery; individualized care plan (ICP); domestic violence and abuse screenings; human immunodeficiency virus (HIV), alpha fetoprotein (AFP), and genetic screenings; Women, Infants, and Children (WIC) referrals; and assessments of infant feeding status.