13.5.                           Documentation Standards

An adequate and complete patient record shall include the following as applicable:

Personal biographical data:

• Patient name and/or identification, birth date, address, primary or secondary phone number, parent/guardian; and;

• Patient name and date of birth on each sheet in the chart.

Each separate encounter/phone contact/entry/report/record shall:

• Be noted as such (i.e. phone contact...);

• Be dated; and

• Be signed or initialed by the practitioner.

Problem list:

• Shall identify and contain significant illnesses and medical conditions past and present;

• Shall be updated and reviewed annually; and

• Shall be dated and signed annually.

Allergies and adverse reactions:

• Must be listed; and

• If the patient has no known allergies or history of adverse reactions, this shall be appropriately noted in the record and easily identified.

History and physicals shall identify and contain:

• Past medical history which includes serious accidents, procedures/surgeries, illnesses, medications;

• Chief complaint;

• Present illness;

• Review of symptoms;

• Pertinent past family and social history;

• Physical examination containing appropriate subjective and objective information pertinent to a patient’s presenting complaints;

• Proposed treatment plan; and

• Working diagnoses consistent with findings.

Medications:

• Dated written provider documentation of current medications with dosages (includes over-the-counter, herbals, vitamin/mineral/dietary supplements) as verified with the patient or authorized representative.

Preventive services/risk screening:

• An immunization record shall be initiated and up to date for each pediatric patient;

• Shall include a growth chart for each pediatric patient; and

• Patients age 14 and over: notations shall exist concerning the use of cigarettes, alcohol and substance abuse.

Orders/referrals:

Progress notes shall include:

• A separate entry for each date of service;

• Chief complaint;

• Treatment plans consistent with diagnosis;

• Unresolved problems;

• Results of pertinent lab/test findings;

• Preventive/wellness issues addressed;

• Health education;

• Plan of care and treatment including but not limited to consultations, medications; (prescribed, dispensed, or administered) and/or diagnostic testing; and

• Any informed consent for office procedures.

Test results:

• Consults, labs, and tests shall reflect physician review; and

• Follow-up care, if indicated, shall be duly noted and signed.

• Calls and content of phone calls shall be documented.

• Records from prior treating or consulting physicians shall be documented.

Advance Directives:

• Shall include documentation by a treating physician of the Advance Directive disclosed by the patient.

Consultative report:

• Shall be considered an adequate medical record for a radiologist, pathologist or a consulting physician.

Corrections, additions or changes in any patient record made more than forty-eight hours after the final entry in the record:

• Shall be signed by the practitioner;

• Shall be clearly marked and identified as such; and

• Shall include the date, time and name of the person making the correction, addition or change.