OCPHN Regional Nurse Consultant Unit

Clinical Record Review Documents and Tools

• Clinical Record Review Best Practices
• OCPHN Updated EM CPT Clinical Record Review Tool - Updated in September 2023
• CPT Clinical Record Review Instructions - New in June 2022
• CPT Clinical Record Review Tracking Form - New in June 2022

Documentation Guidance

• Medical Record Documentation Policy Guidelines - New in December 2022
• NC Medical Board Position Statement: Medical Records
• NC Board of Nursing (NCBON) 21 NCAC 36 .0224 Components of Nursing Practice for the Registered Nurse
• NCBON Fall 2016 Bulletin, page 7, #3 - Failed to Maintain an Accurate Patient Medical Record

Problem Oriented Health Record (POHR)

For DPH program forms (including POHR forms) see program websites.

Policy and Procedure Guidance and Template

• Policy and Procedure Development
• Sample Policy & Procedure Template
• Policy & Procedure Practical Applications

Standing Order Guidance and Template

• Standing Order Guidance
• OCPHN Standing Order Template

Training

• Webinar: 2021 E/M Changes with 2022 Update
  • Link to Recording
  • Link to Handout
• Webinar: Standing Orders 1/31/2022
  • Link to Handout (PDF)