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<p>The North Carolina Medical Board takes the position that an accurate, current and complete medical record is an essential component of patient care.  Licensees should maintain a medical record for each patient to whom they provide care.  The medical record should contain an appropriate history and physical examination, results of ancillary studies, diagnoses, and any plan for treatment.  The medical record should be legible. When the care giver does not handwrite legibly, notes should be dictated, transcribed, reviewed, and signed within a reasonable time.  The Board recognizes and encourages the trend towards the use of electronic medical records (“EMR”).  However, the Board cautions against relying upon software that pre-populates particular fields in the EMR without updating those fields in order to create a medical record that accurately reflects the elements delineated in this Position Statement.  </p> <p>The medical record is a chronological document that: </p><ul class="bullet"><li>records pertinent facts about an individual’s health and wellness;</li> <li>enables the treating care provider to plan and evaluate treatments or interventions;</li> <li>enhances communication between professionals, assuring the patient optimum continuity of care; </li> <li>assists both patient and physician to communicate to third party participants;</li> <li>allows the physician to develop an ongoing quality assurance program;</li> <li>provides a legal document to verify the delivery of care; and </li> <li>is available as a source of clinical data for research and education.</li> </ul> <p>The following required elements should be present in all medical records: </p> <ol class="number"><li>The record reflects the purpose of each patient encounter and appropriate information about the patient’s history and examination, and the care and treatment provided are described.</li> <li>The patient’s past medical history is easily identified and includes serious accidents, operations, significant illnesses and other appropriate information.</li> <li>Medication and other significant allergies, or a statement of their absence, are prominently noted in the record.</li> <li>When appropriate, informed consent obtained from the patient is clearly documented.</li> <li>All entries are dated.</li></ol> <p>The following additional elements reflect commonly accepted standards for medical record documentation.  </p><ol class="number"><li>Each page in the medical record contains the patient’s name or ID number.</li> <li>Personal biographical information such as home address, employer, marital status, and all telephone numbers, including home, work, and mobile phone numbers.</li> <li>All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, initials, or a unique electronic identifier.</li> <li>All drug therapies are listed, including dosage instructions and, when appropriate, indication of refill limits.  Prescriptions refilled by phone should be recorded.</li>  <li>Encounter notes should include appropriate arrangements and specified times for follow-up care.</li> <li>All consultation, laboratory and imaging reports should be entered into the patient’s record, reviewed, and the review documented by the practitioner who ordered them. Abnormal reports should be noted in the record, along with corresponding follow-up plans and actions taken.  </li> <li>An appropriate immunization record is evident and kept up to date. </li> <li>Appropriate preventive screening and services are offered in accordance with the accepted practice guidelines.</li></ol> <a href="http://www.ncmedboard.org/position_statements/detail/medical_record_documentation/" title="Medical record documentation">Visit Article</a>

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