Requirements for Medical Records
Medical records must state the necessity for and the extent of services provided. The following requirements may vary according to the service rendered:
• Description of what was done during the visit;
• History;
• Physical assessment;
• Chief complaint on each visit;
• Diagnostic tests and results;
• Diagnosis;
• Treatment plan, including prescriptions;
• Medications, supplies, scheduling frequency for follow-up or other
services;
• Progress reports, treatment rendered;
• The author of each (medical record) entry must be identified and must
authenticate his or her entry by signature, written initials or computer
entry;
• Dates of service; and
• Referrals to other services.
