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 February 2024
- CPT Clinical Record Review Instructions - New in June 2022
- CPT Clinical Record Review Tracking Form - New in January 2024
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