Name of Manual - Blue Cross and Blue Shield of Minnesota

Quality Improvement
Treatment Record
Documentation
(continued)
Medication Management
• Significant illnesses, clinical risks, and medical conditions are
to be clearly noted and revised periodically.
• Current medications prescribed by all prescribing physicians
must be listed. Dosages and dates of initial prescription and/or
refills must be documented.
• Evidence of informed patient consent for the receipt of
medication must be documented.
• Laboratory orders and results must be documented as well as
review of the results by the ordering physician. If abnormalities
are found, follow-up plans must be documented.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (08/11/11) 3-27