The Basics

This standard outlines the requirements for your organization's P&Ps assuring that your participating providers keep proper records on your consumers.  The records must:

• be complete and organized
• be maintained consistently and contain
  • the consumer's name and ID number on each page,
  • a record of significant illnesses and conditions,
  • a list of allergies and reactions to medications,
  • medical history,
  • diagnoses that are consistent with the provider's findings, and
  • treatment plans that make sense in light of the diagnosis.

Management Tips

Naturally, your P&Ps will require that you provide your participating providers with your expectations regarding how they keep medical records.  Make sure you document how you communicate those expectations to providers.

In addition, your P&P should address how you will perform periodic audits of your high-volume providers to make sure they are fulfilling your expectations.  Again, make sure you have a sound mechanism for documenting your audits.

URAC Accreditation Tips

For the desktop review, submit your P&P regarding medical records.

The onsite review will be conducted by a physician who will examine 50 medical records from high-volume participating providers.  Talk to your lead URAC reviewer about the method for selecting and preparing those files.