patient name and identification data should be written on ..... of patient record options h 1 front page 2last page 3every page 4 middle page
Answers
1. Each page in the record contains the patient’s name or ID number.
2. Personal biographical data include the address, employer, home and work telephone numbers and marital status.
3. All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature,
unique electronic identifier or initials.
4. All entries are dated.
5. The record is legible to someone other than the writer.
*6. Significant illnesses and medical conditions are indicated on the problem list.
*7. Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or
history of adverse reactions, this is appropriately noted in the record.
*8. Past medical history (for patients seen three or more times) is easily identified and includes serious accidents,
operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal
care, birth, operations and childhood illnesses.
9. For patients 12 years and older, there is appropriate notation concerning the use of cigarettes, alcohol and substances
(for patients seen three or more times, query substance abuse history).
10. The history and physical examination identifies appropriate subjective and objective information pertinent to the
patient’s presenting complaints.
11. Laboratory and other studies are ordered, as appropriate.
*12. Working diagnoses are consistent with findings.
*13. Treatment plans are consistent with diagnoses.
14. Encounter forms or notes have a notation, regarding follow-up care, calls or visits, when indicated. The specific time of
return is noted in weeks, months or as needed.