Guidelines For Medical Record Review
Note: The following questions will be answered by either yes, no, or not applicable, followed by comments for areas of improvement.
Do all pages contain patient ID?
Is there biographical/personal data?
Is the provider identified on each entry?
Are all entries dated?
Is the record legible?
Is there a complete problem list?
Are allergies and adverse reactions to medications prominently displayed?
Is there an appropriate past medical history in the record?
Is there documentation of smoking habits and history of alcohol use or substance abuse?
Is there a pertinent history and physical exam?
Are lab and other studies ordered as appropriate?
Is working diagnosis consistent with findings?
Are plans of action/treatment consistent with diagnosis(es)?
Is there a date for return visit or other follow-up plan for each encounter?
Are problems from previous visits addressed?
Is there evidence of appropriate use of consultants?
Is there evidence of continuity and coordination of care between primary and specialty physicians?
Do consultant summaries, lab, and imaging study result reflect primary care physician review?
Does the care appear to be medically appropriate?
Is there a completed immunization record?
Are preventive services appropriately used?
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