| 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. |
