The medical record shall include a description of the pain, a presumptive diagnosis for the origin of the pain, an examination appropriate to the complaint, a treatment plan, and the medication prescribed or administered to include the date, type, dosage, and quantity prescribed or administered.
18 Va. Admin. Code § 85-21-50
Statutory Authority: §§ 54.1-2400 and 54.1-2928.2 of the Code of Virginia.