Aug. 12, 2025
Our annual virtual audit of medical charts from contracted Independent Physician Association providers begins in August 2025. As part of the audit, we request a random sample of 2024 charts from primary care and behavioral health providers. We collect this data to support quality care for members.
Next steps: We’ll email IPAs chosen for the audit by the end of August. If you’re notified, watch for a follow-up email from us with instructions on submitting charts.
Record requirements: We require providers to maintain an active medical record for each member who receives health care services. Medical records should be kept current, complete and legible.
Patient authorization isn’t required to release these records, as their collection and review is considered a component of health care operations under the Health Insurance Portability and Accountability Act of 1996.
The medical chart types we request are:
- Pediatric preventive care and wellness visit notes, including immunizations
- Adolescent preventive care and wellness visit notes
- Adult preventive care and wellness visit notes
- Behavioral health progress notes
Required medical chart documentation and notes include but aren’t limited to:
- Current demographic information
- History and physical
- Past medical and surgical history
- Family and social history
- Current and past alcohol, smoking and illicit drug use (adolescent and adult)
- Depression screening (adolescent and adult)
- Preventive care lab results and radiology reports, such as mammogram, colonoscopy and Pap test
Update the following annually:
- For adults: Demographic, past medical and surgical history, family and social history
- For adults and adolescents: Smoking history, physical activity assessment and counseling, and BMI
If you have questions, please email the Quality Improvement audit team.