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Managed Care Guidelines

Every Page contains the patient's name or ID number. Working diagnoses are consistent with findings.
The record includes appropriate personal and biographical data. Treatment plans are consistent with diagnoses.
Every entry includes author identification and date. Follow-up care is noted as appropriate, with time of return specified or noted as PRN.
The record is legible to someone other than the writer. Unresolved problems are addressed in subsequent visits.
Significant illnesses and conditions are included in the problem list. Consultants are used appropriately and their reports are included in the record.
Medication allergies and adverse reactions are prominently noted. Reports filed with the record are initialed to signify that the physician has reviewed them.
If the patient has been seen three or more times, the record includes an appropriate past medical history as well as notes about smoking, alcohol use and substance abuse. There is no evidence that the patient is placed at inappropriate risk.
The history and exam are appropriate for presenting complaints. The record includes an immunization record or history.
Lab and other studies are ordered as appropriate. The record includes evidence that appropriate preventive services have been offered.
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