Member Medical Record. The Contractor will ensure that a complete Medical Record will be maintained for each Member in accordance with Title 22, CCR, Section 53284, and it will reflect all aspects of patient care, including ancillary services, and at a minimum will include:
A. Member identification on each page; personal/biographical data in the record.
B. All entries dated and author identified; the entries will include at a minimum, the subjective complaints, the objective findings, and the plan for diagnosis and treatment.
C. The record will contain a problem list, a complete record of immunizations and health maintenance or preventive services rendered.
D. Allergies and adverse reactions are prominently noted in the record.
E. All informed consent documentation, including the human sterilization consent procedures required by Title 22, CCR, Sections 51305.1 through 51305.6, if applicable.
F. All emergency care provided (directly by the contracted provider or through a emergency room) and the hospital discharge summaries for all hospital admissions while the patient is enrolled.
G. All consultations, referrals, and specialists' reports, and all pathology and laboratory reports. Any abnormal results will have an explicit notation in the record.
H. For Medical Records of adults, documentation of whether the individual has been informed and has executed an advanced directive such as a Durable Power of Attorney for Health Care. Xxxxxx Medical Centers 95-23637 Article VI
I. Request or refusal of language/interpretation services.
J. Health education behavioral assessment and referrals to health education services. For patients 12 years or older, a notation concerning use of cigarettes, alcohol, and substance abuse, health education or counseling and anticipatory guidance.
Member Medical Record. Contractor shall ensure that a complete Medical Record is maintained for each Member and the record reflects all aspects of patient care, including ancillary services, and at a minimum includes:
a) Member identification on each page; personal/biographical data in the record;
b) All entries dated and author identified; the entries will include at a minimum, the subjective complaints, the objective findings, and the plan for diagnosis and treatment;
c) A problem list, a complete record of immunizations and health maintenance or preventive services rendered;
Member Medical Record. Contractor shall ensure that a complete medical record is maintained for each Member in accordance with Title 22, CCR, Section 53861, that reflects all aspects of patient care, including ancillary services, and at a minimum includes:
1) Member identification on each page; personal/biographical data in the record.
2) Member’s preferred language (if other than English) prominently noted in the record, as well as the request or refusal of language/interpretation services.
3) All entries dated and author identified; for member visits, the entries shall include at a minimum, the subjective complaints, the objective findings, and the plan for diagnosis and treatment.
4) The record shall contain a problem list, a complete record of immunizations and health maintenance or preventive services rendered.
5) Allergies and adverse reactions are prominently noted in the record.
6) All informed consent documentation, including the human sterilization consent procedures required by Title 22, CCR, Sections 51305.1 through 51305.6, if applicable.
7) Reports of emergency care provided (directly by the contracted provider or through an emergency room) and the hospital discharge summaries for all hospital admissions.
