All entries are legible to individuals other than the author, dated (month, day, and year), and signed by the performing provider.

Mandatory

Each page of the medical record documents the client's name and CSHCN Services Program client identification number.

Mandatory

Allergies and adverse reactions (including immunization reactions) are prominently noted in the record.

Mandatory

The selection of evaluation and management codes (levels of service) is supported by the client's clinical record documentation. The American Medical Association's (AMA's) Current Procedural Terminology (CPT) descriptors of key/contributory components with level of service descriptions are used to evaluate the selection of levels of service.

Mandatory

Necessary follow-up visits specify the time of return by at least the week or month.

Mandatory

The history and physical documents the presenting complaint with appropriate subjective and objective information, e.g., medical and surgical history, current medications and supplements, family history, social history, diet, pertinent physical examination measurements and findings, etc.

Mandatory

The services provided are clearly documented in the medical record with all pertinent information regarding the client's condition to substantiate the need for the services.

Mandatory

Medically necessary diagnostic lab and X-ray results are included in the medical record, and abnormal findings include an explicit notation of follow-up plans.

Mandatory

Unresolved problems are noted in the record.

Mandatory

Immunizations are noted in the record as complete or up-to-date.

Mandatory

Personal data includes address, employer, home and work telephone numbers, sex, marital status, and emergency contacts.

Desirable