Medical Record Standards
1. Organized, individual medical records
2. Organized filing system for medical records
3. Confidentiality/security of medical information assured
4. Release of information documents signed
5. Record notes whether or not adult patient has signed an Advanced Directive
6. Plan of care developed within seven days of admission and updated interdisciplinary review and revision as appropriate
7. Patient safety assessments (i.e., fall risk/skin breakdown) completed per facility policy
8. Patient rights and responsibilities documented