1.1 Full identification on ALL pages of the consultation report (minimum: first name, last name, date of birth) Patient label is ideal

1.2 Filed correspondence is for the correct patient

1.3 Archived results are for the correct patient

1.4 Patient labels are correct and current

1.5 Medical record file/cover is in good working order

1.6 Documents are in reverse chronological order (most recent at the top)

1.7 Documents are separated into appropriate tabs, eg. results tab

2.1 Pathology is labeled/filed correctly

2.2 Diagnostic images are labeled/archived correctly

2.3 Electronic letters are for the right patient

2.4 Scanned documents are for the right patient

2.5 Electronic Letters – FORWARDED

2.6 Electronic Letters – RETURNED

2.7 Electronic Charts – DISTRIBUTED

3.1 The general practitioner is registered in the patient registration screen

3.2 Marital status is recorded on the patient record screen (if known)

3.3 The titer is recorded on the patient record screen

3.4 The next of kin is registered

3.5 Copy doctors are on the referral screen

3.6 If deceased, the record is marked as “deceased” on the patient record screen

3.7 If deceased, the record is marked as “Status of” on the patient record screen

3.8 If deceased, date of death is recorded