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Medical Records

Medical record documentation standards

CHWP has established standards for the administration of medical records to ensure medical records conform to good professional medical practice, support health management and permit effective member care. A good medical records management system not only provides support to clinical participating providers in the form of efficient data retrieval but also makes data available for statistical and quality of care analyses.

The medical record serves as a detailed analysis of the member’s history, a means of communication to assist the multidisciplinary health care team in providing quality medical care, a resource for statistical analysis, and a potential source of defense to support information in a lawsuit. It is the participating provider’s responsibility to ensure not only completeness and accuracy of content but also the confidentiality of the health record. CHWP requires that the provider adhere to the standards for maintaining member medical records and to safeguard the confidentiality of medical information.

Participating providers are responsible for responding to demands for information while protecting the confidentiality interests of CHWP members. All participating providers must have policies and procedures that address confidentiality and the consequences of improper disclosure of protected health information (PHI). Providers should refer to www.cahealthwellness.com under For Providers > Provider Resources > Manuals, Forms and Resources > Manuals > Provider Manual/Billing Manual to review specific levels of security of medical records that must be addressed by the participating provider’s policies and procedures governing the confidentiality of medical records and the release of members’ PHI.

CHWP monitors medical record documentation compliance and implements appropriate interventions to improve medical recordkeeping. Medical record guidelines are available through www.cahealthwellness.com or upon request by contacting CHWP Provider Services.