Ill. Admin. Code tit. 77 § 240.90

Current through Register Vol. 48, No. 49, December 6, 2024

Section 240.90 - HMO Provider Site Medical Record Requirements

a) The HMO shall require each provider to maintain an active record for each enrollee who receives health care services. This record shall be kept current, complete, legible and available to the medical and administrative staff of the HMO and to the Department's representatives.

b) The HMO shall require that each entry be indelibly added to the enrollee's record, dated and signed or initialed by the person making the entry. The HMO shall require each provider site to have a means of identifying the name and professional title of the individual who makes each entry.

c) The medical record for each enrollee who has had a routine, scheduled appointment with one of the HMO's primary care physicians shall include the following information:

1) identification,

2) patient history,

3) known past surgical procedures,

4) known past and current diagnoses and problems, and

5) known allergies and untoward reactions to drugs.

d) The basic information collected pursuant to subsection (c) above shall be made available to each HMO provider with whom the enrollee has a scheduled encounter.

e) The HMO provider site shall not be expected to have the basic information described in subsection (c) above for an enrollee whose only encounters with the HMO are unscheduled or of an emergency nature.

f) The HMO shall require that the medical records for each enrollee who receives health care services contain the following information regarding each episode of care.

1) reason for the encounter,

2) evidence fo the provider's assessment of the enrollee's health problems,

3) current diagnosis of the enrollee, including the results of any diagnostic tests,

4) plan of treatment, including any therapies and health education, and

5) if the basic information outlined in subsection (c) above is not available, any medical history relevant to the current episode of care.

g) The HMO shall require each provider site to document that all outcomes of ancillary reports, such as laboratory tests and x-rays have been reviewed by the provider who ordered the reports. The HMO shall require each provider site to document that follow up actions have been taken regarding report results that are deemed significant by the provider who ordered the report.

Ill. Admin. Code tit. 77, § 240.90