1. The medical record should be complete and legible

2. The documentation of each patient encounter should include:

a. the chief complaint and/or reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;

b. assessment, clinical impression or diagnosis;

c. plan for care; and

d. date and a verifiable legible identity of he health care professional who provided the service

3. If not specifically documented, the rationale for ordering diagnostic and other ancillary services should be able to be easily inferred

4. Past and present diagnoses and conditions should be accessible to the treating and/or consulting physician

5. Appropriate health risk factors should be identified

6. The patient's progress, response to and changes in treatment, planned follow-up care and instructions, and diagnosis should be documented

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record

8. An addendum to a medical record should be dated the day the information is added to the medical record and not dated for the date the service was provided

9. Timeliness: A service should be documented during, or as soon a practicable after it is proved in order to maintain an accurate medical record

10. The confidentiality of the medical record should be fully maintained consistent with the requirements of medical ethics and of law.