• The record must be legible to someone other than the writer.
• Every page in the record must contain the beneficiary’s name or ID number.
• Personal/biographical data should include address, employer, home and work telephone numbers, and marital status.
• All entries in the medical record should contain author ID, which may be a handwritten signature, unique electronic identifier, or initials.
• All entries must be dated.
• Significant illnesses and medical conditions must be indicated on a problem list.
• Medication allergies and adverse reactions, if any, should be prominently noted in the record.
• Medical history (for beneficiaries seen three or more times) should be easily identifiable and include serious accidents, operations, and illnesses.
• For children and adolescents (18 years and younger), medical history should relate to prenatal care, birth, operations, and childhood illnesses.
• For beneficiaries 14 years and older who have been seen three or more times, information concerning use/abuse of cigarettes, alcohol, and controlled substances should be noted.
• Histories and physicals should contain appropriate subjective and objective information for presenting complaints.
• Laboratory and other studies should be ordered, as appropriate, and documented properly.
• Working diagnoses should be consistent with findings.
• Treatment plans should be consistent with diagnoses.
• Encounter forms or notes should have a notation, when indicated, regarding follow-up care, calls, or visits, and the specific time of return should be noted in weeks, months, or “as needed.”
• Unresolved problems from previous office visits should be addressed in subsequent visits.
• Reviews should be conducted for underutilization or overutilization of consultants.
• Consultant notes/results for a requested consultation must be entered on the chart.
• To signify review, all consultation, laboratory, and imaging reports filed in the chart should be initialed by the ordering practitioner. Review and signature by professionals other than the ordering practitioner do not meet this requirement. If the reports are presented electronically or by some other method, review by the ordering practitioner should be documented.
• Consultation, abnormal laboratory, and imaging study results should include an explicit notation of follow-up plans in the record.
• Individual records should be used to demonstrate whether the care was needed and if it was of such quality to meet the beneficiary’s needs.
• Immunization records for children must be up-to-date, and an appropriate history must be made in the medical records for adults.
• Evidence that preventive screening and services were offered and accepted or rejected in accordance with the office’s practice guidelines should be included in the record.
• In cases of unusual deaths, or in deaths of medical-legal and education interest, there should be documentation of request (consent or refusal) for an autopsy.
• Medical record documentation of injection(s) should include:
  • Name of drug
  • Lot number
  • Time of administration
  • Dosage
  • Route of administration
  • Site of injection
  • Signature or initials of individual administering the medication
  • For immunizations: lot number, manufacturer, verification that the Vaccine Information Statement was given to the patient or parent/ guardian, and the name and address of the health care provider administering the vaccine.

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