RC.01.01.01 The practice maintains complete and accurate clinical records.

EP5 Information on the medical record

X

Record of Care, Treatment, and Services (RC) Standards

RC.01.01.01 The practice maintains complete and accurate clinical records.
RC.02.01.01 The clinical record contains information that reflects the patient's care, treatment, and services.
- EP2 Clinical information
RC.02.01.03 The patient's clinical record contains documentation on any operative or other high-risk procedures and the use of moderate or deep sedation or anesthesia.

Element of Performance

The medical record includes the following:

Information needed to support the patient’s diagnosis and condition
Information needed to justify the patient’s care, treatment, and services
Information that documents the course and result of the patient's care, treatment, and services
Information about the patient’s care, treatment, and services that promotes continuity of care among providers

Resources

Access Options

If you would like to learn more about purchasing a facility subscription to this content, please click the button below.

Learn More