Each page requires the patient name or identifier, the date of the entry and the author’s signature (as appropriate).
||Presenting Complaints, Diagnoses, Labs, X-rays, Consults, and Other Diagnostic Tests Have a Plan for Treatment Documented in the Patient Record:
All complaints, diagnoses, and reports must have documentation of a treatment plan for continued evaluation and/or abnormal results.
A problem list with the patient’s ongoing, chronic medical/psychological conditions and/or significant illnesses must be maintained in the patient record. Notation in the record is acceptable. If there are no identified problems, there must be a notation in the record stating that this is a well adult.
There is a medication list, which includes dosages and dates for initial and refill prescriptions. Notation in the record is acceptable.
Allergies and adverse reactions must be specified and prominently documented in the patient record on all patients. If a patient has no allergies, this must be documented prominently in the patient record as NKA or NKDA (no known allergies or no known drug allergies).
There should be documentation present in the records of all patients 45 years or older that advance directives have been discussed. If the patient chose to make an advance directive (in the past or present), there should be a copy of the advance directive in a prominent part of the member record. Notation should also be made if the patient does not want to make an advance directive.
||Past Medical History:
Records should include notation of past medical history including physical exams, necessary treatment, and possible risk factors relevant to a particular treatment.
Documentation of assessment and treatment (if appropriate) for, or discussion of incontinence issues or concerns.
Documentation of discussion (if appropriate) regarding level of exercise and/or physical activity, balance walking or falls.
The record must be readable and the contents comprehendible.