Ala. Admin. Code r. 545-X-4-.09

Current through Register Vol. 43, No. 1, October 31, 2024

Section 545-X-4-.09 - Minimum Standards For Medical Records

The maintenance of adequate medical records is an integral part of good medical care. Adequate records are necessary to ensure continuity of care, not only by the physician who maintains a particular record, but by other medical professionals. Therefore, every physician licensed to practice medicine in Alabama shall maintain for each of his or her patients, a record which, in order to meet the minimum standard for medical records, shall:

(1) be legible, and written in the English language;

(2) contain only those terms and abbreviations that are or should be comprehensive to other medical professionals;

(3) contain adequate identification of the patient;

(4) indicate the date any professional service was provided;

(5) contain pertinent information concerning the patient's condition;

(6) reflect examinations, vital signs, and tests obtained, performed, or ordered and the findings or results of each;

(7) indicate the initial diagnosis and the patient's initial reason for seeking the physician's services;

(8) indicate the medications prescribed, dispensed, or administered and the quantity and strength of each;

(9) reflect the treatment performed or recommended; document the patient's progress during the course of treatment; and

(10) include all patient records received from other health care providers, if those records formed the basis for a treatment decision by the physician.

Ala. Admin. Code r. 545-X-4-.09

New Rule: Filed February 25, 2005; effective April 1, 2005.

Amended by Alabama Administrative Monthly Volume XXXVII, Issue No. 03, December 28, 2018, eff. 1/24/2019.

Author: Wayne P. Turner, Attorney for the Medical Licensure Commission

Statutory Authority:Code of Ala. 1975, §§ 34-24-360 -(22)