Name of Manual - Blue Cross and Blue Shield of Minnesota

Quality Improvement
Medical Record
Documentation
Rationale:
The patient medical record is a vehicle for documenting services
provided and evaluating continuity and coordination of care. It also
serves as legal protection for the patient and practitioner. Blue
Cross, per contractual agreement with both the subscriber and
provider, has access to the member’s medical record for
examination and evaluation. Blue Cross’ corporate confidentiality
policy requires that the personal and health information of its
members be maintained as confidential information. All employees
are required to attest to their knowledge of this policy and their
intent to comply with it.
Medical record review is an essential component of a
comprehensive Quality Improvement program. The Blue Cross
Quality Council, which includes practicing physicians, establishes
minimum patient medical record documentation standards.
Requirements:
All providers will have a policy and procedure in place to address
the following:
Format
• The content and format of the medical record is organized and
includes patient’s address and home and work phone numbers.
• Each page in the medical record contains the patient’s name or
identification number.
• All entries in the medical records contain the author’s
identification. Author identification may be a handwritten
signature, a unique electronic identifier, or a stamped signature
verified with initials.
• Medical records are legible to someone unfamiliar with the
author’s handwriting.
• All encounters/entries are dated.
• Immunization status information for all ages is recorded on a
single page location.
• A summary of preventive services screening is documented in
a consistent place.
3-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11)