OCPHN Regional Nurse Consultant Unit

Clinical Record Review Documents and Tools

• Clinical Record Review Internal Auditing Best Practices (PDF)
• Clinical Record Review Tool (PDF) - Updated February 2025
• Clinical Record Review Tracking Form (DOCX) - Updated March 2025
• 2025 - 2027 LTATB/OCPHN Joint Monitoring Schedule (PDF)

Documentation Guidance

• Medical Record Documentation and Abbreviations Policy Guidelines (PDF) - Updated January 2025
• 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
• Standing Order and Policy Development Webinar

Training

Webinar: Standing Orders 1/31/2022 (PDF)