Every Page contains the patient's name or ID number. Working diagnoses are consistent with findings. The record includes appropriate personal and biographical data. Treatment plans are consistent with diagnoses.
Every entry includes author identification and date.
The record is legible to someone other than the writer. Unresolved problems are addressed in subsequent visits. Significant illnesses and conditions are included in the problem list. Consultants are used appropriately and their reports are included in the record. Medication allergies and adverse reactions are prominently noted.