Medical record standards

Blue Shield's established medical record standards are designed to help providers facilitate effective communication, coordination and continuity of care, and healthcare delivery for our members. Blue Shield's performance goal for the standards is 100%.

As part of our commitment of working together with our providers, Blue Shield is offering medical record management tools to make it easier for you to be compliant with your documentation requirements. In addition to providing tools for your overall treatment plan of each patient, these forms will provide the necessary documentation that is reviewed for HEDIS.

By using the following medical record management tools and keeping them updated, HEDIS record submissions can be reduced from more than 50 pages to just a few pages.

Recommended medical record format

 Learn about recommended six-section medical record format

Medical record PDFs

 Adult health maintenance checklist (PDF, 63 KB)

 Adult problem list (PDF, 31 KB)

 Blood pressure flow sheet (PDF, 25 KB)

 CAGE alcohol screen and brief intervention (PDF, 65 KB)

 Child and adolescent immunization flow sheet (PDF, 46 KB)

 Child and adolescent prevention flow sheet (PDF, 45 KB)

 Child and adolescent problem list (PDF, 73 KB)

 Depression screen (PDF, 45 KB)

 Diabetes management record (PDF, 35 KB)

 Medication list (PDF, 35 KB)

 Ophthalmology consultant report  (PDF, 31 KB)