A. The HMO shall maintain or cause the 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. The HMO shall have policies and procedures, as related to medical records, for the review of physicians and other Providers. The policies and procedures shall address, at a minimum, the retention, security, storage, confidentiality, transfer, release, and destruction of medical record information.

B. Each medical record shall contain sufficient information and data to support diagnosis, plan of treatment, and other pertinent medical information such as medical history, progress notes, and other related reports.

C. 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 the entry.

D. The medical record for each Enrollee who has had a routine, scheduled appointment with one of the HMO's Providers shall include basic information collected; as a minimum, identification of the Enrollee, patient history, known past surgical procedures, known past and current diagnoses and problems, and known allergies and untoward reactions to drugs.

E. The HMO shall require that the medical records for each Enrollee who receives Health Care Services include the following information regarding each episode of care:

F. 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 requested 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 requested the report.

G. Arrangements shall be made for the sharing of pertinent medical records among Providers participating in the HMO and for maintenance by the HMO when needed for committee reviews. In all cases, the confidentiality of the record shall be assured.