Entries into the medical record must comply with a number of specific administrative requirements. You must make your entries actually using these letters as the headings for your entries. The subjective complaints and patient history should be a full and accurate account which clearly reflects the patient's report of their problem, symptoms, and pertinent history. Other requirements for documentation include the date, clinic stamp, signature, and signature stamp. All entries into the medical record must include the above requirements and be organized in an orderly fashion.
Legibility is critical and completeness mandatory.
Medical legal experts place high emphasis on the information contained in medical records and it is to your advantage to have your documentation as complete and thorough as possible. Below is a sample of a standard prescription form which may be used for glasses, contact lenses or pharmaceuticals. I understand the risks due to contact lens wear and the rules for their use by aircrew members. After receiving my lenses, I will follow the lens care instructions properly. I further acknowledge, if I fail to meet my required follow-up appointments, I may be prohibited from flying while wearing contact lenses and risk disqualification from the program.