Documentation of Medical Records
As expected of any physician using conventional medical practices or CAM therapies, he/she should keep accurate and complete records to include:
• the medical history and physical examination;
• diagnostic, therapeutic and laboratory results;
• results of evaluations, consultations and referrals;
• treatment objectives;
• discussion of risks and benefits,
• appropriate informed consent,
• medications (including date, type, dosage and quantity prescribed);
• instructions and agreements;
• periodic reviews;
• (if appropriate) patient’s expectations about the therapy.
Records should remain current and be maintained in an accessible manner, and readily available for review stored at a safe place according to the standards for data and privacy protection.