Clear and Legible Reports
Date of Publication:
11/16/2015
Definition:
Specialty care consultation and referral reports, histories and physicals, progress notes, notes on episodes of care, and other patient information (such as laboratory reports, x-ray readings, operative reports), and discharge summaries for beneficiaries referred by an MTF, or reports of any other such care provided without a referral, in accordance with Part 2 of Title 42, Code of Federal Regulations.
Source of Definition:
DOD Health Record Life Cycle Management