|Every Page contains the patient's name or
||Working diagnoses are consistent with
|The record includes appropriate personal
and biographical data.
||Treatment plans are consistent with
|Every entry includes author identification
||Follow-up care is noted as appropriate, with
time of return specified or noted as PRN.
|The record is legible to someone other than
||Unresolved problems are addressed in subsequent
|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
||The record includes an immunization record
|Lab and other studies are ordered as
||The record includes evidence that appropriate
preventive services have been offered.