Medical recordkeeping
Definition
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.