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. (1) be legible, and written in the English language;
2. (2) contain only those terms and abbreviations that are or should be comprehensive to other medical professionals;
3. (3) contain adequate identification of the patient;
4. (4) indicate the date any professional service was provided;
5. (5) contain pertinent information concerning the patient’s condition;
6. (6) reflect examinations, vital signs, and tests obtained, performed, or ordered and the findings or results of each;
7. (7) indicate the initial diagnosis and the patient’s initial reason for seeking the physician’s services;
8. (8) indicate the medications prescribed, dispensed, or administered and the quantity and strength of each;
9. (9) reflect the treatment performed or recommended; document the patient’s progress during the course of treatment; and
10. (10) include all patient records received from other health care providers, if those records formed the basis for a treatment decision by the physician.

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

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

History: New Rule: Filed February 25, 2005; effective April 1, 2005. Amended: Filed December 10, 2018; effective January 24, 2019.