Medical Record Keeping Guidelines

CareFirst CHPDC is committed to partnering with our contracted practitioners and providers in providing our enrollees with the highest possible quality of care.

Consistent, current and complete documentation is an essential component of quality patient care. The medical record must “tell the story” of the patient as determined by the physician in the circumstances in which he or she saw the patient. The record is not just a personal memory aid for the individual physician who creates it. It must allow other health care providers to read quickly and understand the patient’s past and current health concerns. Efficient medical record keeping facilitates current and future medical treatment of individuals by recording which treatments have and which have not been effective, and the degree to which they have been effective as well as preventing harmful interactions attributable to different medical treatments.

In recognition of the key role that medical records play in providing clinical care, and to promote best-practice medical record keeping, we have adopted the components identified by the National Committee for Quality Assurance (NCQA) as our standard for medical record keeping. These guidelines have been incorporated into our ongoing quality oversight of contracted practitioners and providers.