Medical record documentation standards

Blue Shield of California Promise Health Plan’s goal is to ensure each patient has a legible, detailed, well-organized, confidentially stored, and easily retrievable medical record. These records need to be consistent with standard medical and professional practice and meet the standards of oversight organizations, including Blue Shield Promise and regulatory agencies.

Recommended six-section medical record format

Section I

• A patient information sheet should always be on top of all other forms in this section.
• The signed general consent for treatment and all other consent forms (IUD, sterilization, surgery, etc.) must remain in the chart and should be placed in this section.
• Include an authorization for release of medical records.
• Include a copy of the completed Child Health and Disability Prevention (CHDP) eligibility form.
• Include letters to and from the patient and/or his or her agent.

Section II – History and physical progress

Adult charts

• Patient history or database are the top forms filed in this section.
• Problem list
• Medication flow sheet
• Immunization flow sheet
• Hearing and vision screen record
• History and physical forms

Pediatric charts

• CHDP health guidelines
• Age-specific assessment form
• Problem list medication flow sheet
• Medication flow sheet
• Immunization flow sheet
• Hearing and vision screen record
• Growth charts
• Lead screening questionnaire
• Nutrition screening form
• Episodic visit
• PM 160 forms (CHDP forms)

Section III – Laboratory

• Laboratory reports are to be filed in reverse chronological order, with the most current data on the top.
• Reports too large to mount on the form should be taped to a regular piece of paper and filed on a mounting form.

Section IV – X-ray and EKG

• File in reverse chronological order with EKG results separated from one another.

Section V – Consult/referral

• File in reverse chronological order with EKG results segregated from one another.
• Referral information, such as correspondence directed to an outside agency, physician, health facility, etc., regarding the medical information contained in this particular patient's medical record
• Copies of requests for referral/consultation are filed in this section until the report is received, at which time the report is filed and the request is discarded.
• Copy of medical records from previous medical practitioners
• Hospital discharge summaries
• Emergency room records

Section VI – Miscellaneous

• Complete obstetrics records on inactive obstetrics cases
• Correspondence with insurance companies or health plans
• Back-to-work or back-to-school forms
• Any reports, correspondence, forms, etc., that do not belong in another section
   

If it becomes necessary to start a new volume, label the new chart “Vol. II of II” and label the old chart “Vol. I of II.” The following items should be carried forward to Volume II:

• Consent to treatment form
• Problem Index
• Most recent history and physical forms
• Pertinent history from previous practitioners
• Most recent lab, x-ray, EKG, and progress notes