Medical recordkeeping


The office documents that support:

  • Charging practices.
  • Accounts receivable.
  • Type of service performed.
  • That the service was actually performed.
  • Medical necessity of the service.

These records would include but not be limited to:

  • Appointment books.
  • Ledgers.
  • Invoices.
  • Exam findings.
  • Daily progress notes.
  • Histories and physicals.
  • Lab and x-ray reports.
  • Consultation reports.

A contracting provider agrees to make this information available to BCBSKS at no charge. Accepted methods of documentation for daily medical records include Subjective, Objective, Assessment and Plan – SOAP Notes and History, Exam, Assessment and Layout – HEAL.