Medical-Record Documentation
Providers are responsible for documenting each patient encounter completely, accurately, and timely. Accurate documentation supports compliance with federal and state laws and reduces fraud, waste, and abuse. These medical-record documentation guidelines are provided to help ensure that VSP network doctors meet VSP’s documentation requirements. Inadequate documentation may result in the denial of services.
Requirements
A medical record is a written or electronic health record of a patient’s medical history and clinical data associated with a patient’s care, including patient demographics, patient medical and family history, examination and evaluation notes, and all data and reports related to point of care assessment, testing, diagnosis, and treatment.
Medical records include and are not limited to:
- Patient history questionnaires or intake forms
- Exam chart notes, progress notes, orders, and prescriptions
- Diagnostic testing and results
- Referral summaries and patient communications
- Correspondences between interprofessional health care providers
- Optical records and lab order forms, including spectacle and contact lens order forms
- CMS-1500 Claim Forms, superbills, and eClaim patient printouts
- Physician orders for services provided in long-term care facilities
Providers are responsible for accurate documentation and claim submission of services performed. Claims should be coded appropriately according to industry standard coding guidelines including, but not limited to American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-10 CM), and National Correct Coding Initiative (NCCI).
All medical record entries must be complete, legible, dated, and include the legible signature of the doctor providing care, consistent with Centers for Medicare & Medicaid Services (CMS) policies and procedures, or as required by federal/state laws. Any encounter between the doctor, clinical staff, and the patient must be documented in the patient’s medical record.
In compliance with CMS, VSP network doctors are required to maintain medical records for seven years from the date of service, or as required by federal and state laws. Medicare managed care program providers are required to retain records for ten years from the date of service, or as required by federal and state laws.
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Medical Record Requirements |
Description |
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Medical record |
Ensure all procedures are documented according to industry standard coding guidelines. Undocumented procedures are considered not performed unless the test was attempted and there is documentation as to why results were not obtained. Examples may include but are not limited: to the patient is non-verbal, non-responsive, uncooperative, refused testing, etc. |
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Claim date of service |
The date of service for the patient encounter must reflect the date of service on the claim. |
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Past medical history |
Document or review the patient’s ocular and medical history, which includes but is not limited to diseases and illnesses currently being treated, surgical history, family medical history, social history, allergies, medications, and the date of last eye exam or refractive prescription. |
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Chief complaint and history of present illness |
Document the reason for the visit as stated in the patient’s own words. Document the description of the present illness with reference to onset, location, duration, severity, etc. as related to the chief complaint. |
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Consistent diagnoses, exam findings, and treatment plans |
A valid ICD-10-CM diagnosis must be documented for each patient encounter and supported by the documented clinical findings. Documentation should include all recommended treatments, diagnostic testing, and follow-up care instructions. Treatment plans must be appropriate and consistent with the diagnosis. |
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Follow-up care/visits |
Medical record documentation must indicate the patient’s follow-up care cadence. Computerized recall documentation alone is insufficient. Electronic records must have recall dates present within the medical record and a doctor identifier must also be present. |
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Signature requirements |
Signatures for each entry must be legible and should include the practitioner’s first and last name, and applicable credentials. The practitioner’s signature or initials in patients’ medical records and chart notes demonstrate that services submitted have been completely and accurately documented, reviewed, and authenticated. Furthermore, it confirms the provider has certified the medical necessity for the service(s) submitted to VSP for payment consideration. |
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Avoid potential risks for patients |
Doctor interventions should be appropriate for the patient history, clinical findings, and diagnosis. There should be no indication that a patient was placed at potential risk due to diagnostic or therapeutic procedures provided or not provided. |
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Appointment timing |
If an appointment is delayed or extended, note in the relevant record that a longer waiting time would not have a detrimental effect on the health of the patient. |
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Preferred written and spoken language |
Document preferred written and spoken language on the patient history form and/or medical record. |
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Use of interpreter |
Document the use of an interpreter in the patient’s medical record when a patient receives interpreter services, including who provided the interpretation (trained professional interpreter, office staff, etc.) |
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Refusal of interpreter |
If a patient prefers a language that is not provided in the office and refuses the use of a trained professional interpreter, document the refusal in the patient’s medical record. Note: A trained professional interpreter does not include friends or family members, unless the person is professionally trained, including knowledge of medical terminology. |
Note:
For California patients, include the following documentation. Refer to the VSP Members Language Assistance Program for more information.