Medi-Cal Medical Record Documentation Standards
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
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 are excerpts, but not limited to only these criteria and 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). If a primary language other than English is noted and forms in the member’s medical record are in another language, there must be an English version of that form in that member’s medical record also.
- 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 an adult family member or friend as an interpreter.
- Documentation - Medical record entries and corrections must be documented in accordance with acceptable legal medical documentation standards; allergies and reactions, 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 and reviewed every 5 years.
- 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. This includes risk assessments such as Adverse Childhood Experiences (ACEs), Social Determinants of Health (SDOH) with 120 days of enrollment and yearly thereafter.
- 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, vaccine administration documentation and vaccine information status publication date, 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, colon CA screening, obesity, diabetes, osteoporosis, Hep B & C, HIV, sexually transmitted infections (STI), alcohol/drug/tobacco and intimate partner violence screening.
- 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, depression, suicide risk, sudden cardiac arrest and sudden cardiac death, STI, alcohol/drug/tobacco screening.
- 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, maternal depression, psycho social, family planning.