MN ADC 9505.2175

Health Service Records

As a condition for payment under a medical assistance program such as Medicaid, the provider or vendor must document each instance of health service provided to a patient.  The health service record must include the following:

1)      Date the entry is made;

2)      Date the health service was provided;

3)      Length of time spent with the patient if payment depends on time spent;

4)      Signature and title of the physician or person treating the patient;

5)      Signature of the vendor or supervisor, when applicable.

The record must state the following:

1)      The patient’s history and health condition;

2)      Results of tests and examinations;

3)      Diagnosis from the examination;

4)      The amount and name of drugs prescribed;

5)      Consultation reports;

6)      Patient’s care plan or individual treatment plan;

7)      Patient’s progress or change in treatment;

8)      X-ray or lab records must document the physician’s order.

Records must also be maintained for pharmacy services, medical transportation service, durable medical equipment, medical supply, rehabilitative or therapeutic services, personal care provider services, school based service, and language interpreter services.