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Ala. Admin. Code r. 545-X-4-.09
Link to the law
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Current as of June 2015
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Minimum Standards for Medical Records
Licensed Alabama physicians must maintain “adequate medical records.” Records are adequate if they: (1) are written legibly in English; (2) use “only those terms and abbreviations that are or should be comprehensive to other medical professions;” (3) identify the patient; (4) document the dates on which services were provided; (5) document information regarding the patient’s condition; (6) document exams, vital signs, and tests; (7) include the patient’s diagnosis; (8) identify medications prescribed or administered to the patient; (9) document the recommended or performed treatment; (10) document the patient’s treatment progress; and (11) contain information from patient records provided by other health care professionals.
Current as of June 2015
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