Clinical records pass an AAAHC survey when every sampled encounter is organised, complete and authenticated, with allergies and reactions documented, outside reports reviewed and incorporated, and access, editing and retention controlled by written policy. Those requirements sit mainly in the Clinical Records (CRD) and Care Management and Coordination (CMC) categories.
The Clinical Records standards
CRD.120 requires a system for accurate collection, processing, maintenance, storage, retrieval and distribution of clinical records, with named responsibility for the records and the health information system. CRD.130 requires written policies on security, confidentiality, access, editing, deletion, backup and retention, including backup for electronic records. CRD.140 and CRD.190 require consistent organisation, encounters that include history, findings, orders, care provided and clear provider authentication, and legible, accessible entries.1
CRD.210 covers allergies, sensitivities and other reactions.2 It was a focus of the 2026 Quality Roadmap, with 17.9% of surgical and procedural organisations and more than 30% of primary care settings needing to improve documentation, and AAAHC says allergy verification should be documented 100% of the time.3 CRD.220 requires reports, progress notes, laboratory reports, x-ray readings and consultations to be reviewed and incorporated into the record.4
What Care Management adds to the record
| Standard | What the record should show |
|---|---|
| CMC.100 | History, physical examination and medication reconciliation consistent with the standard of care |
| CMC.110 | The patient informed about their condition, treatment, follow-up and preventive care |
| CMC.130 | Summaries or records from external providers obtained, incorporated and shared when appropriate |
| CMC.190 | Written pre and postoperative self-care instructions, including medication guidance |
AAAHC warns about documentation habits that undermine records in electronic systems, such as copy and paste, over-reliance on templates and poor control of authorship. It asks for disciplined template design, clear rules for amendments and late entries, and routine auditing.1 Under Patient Rights, Responsibilities, and Protections, role-based access, authentication and timeouts, and audit trails all support compliance.1
- Set a sampling method. Choose records that reflect your workload, clinicians and patient mix, as AAAHC recommends.
- Use the Clinical Record worksheet. Work through the worksheet in the Self-Assessment Tool for each sampled record.
- Check authentication. Every entry is attributable to a named clinician, with a date and time, and amendments are visible.
- Check allergies. Each allergy has the reaction and its severity, verified at the visit.
- Check what came from outside. Results and consultations were reviewed, signed and acted on.
- Check what the patient took home. Written instructions and education are on the record.
- Turn gaps into a QI study. A recurring gap is a candidate for a QUA.240 study.
- Record ______ Clinician ______ Date of service ______
- History, findings, orders, care provided, yes or no ______
- Authenticated with name, date and time ______
- Allergies with reaction and severity ______
- Outside reports reviewed and incorporated ______
- Medication reconciliation ______ Written instructions given ______
- Consent documented ______ Gaps and action ______
AI-drafted notes and the record
AAAHC's guidance on AI recognises ambient scribes as a common use in ambulatory care and warns that language models can produce plausible but inaccurate content. It expects the governing body to set human oversight and review AI's effect on workflows and outcomes.5 From 15 December 2026, v45 adds AI standards on governance, risk, staff training, patient consent, data security and vendor management.3 A note an AI drafts is the clinician's record only once the clinician has read, corrected and signed it.
For the security side in the US, read AI scribes and HIPAA. For how records are sampled in the survey, see the AAAHC survey checklist, and for record topics as QI studies, the QI study guide.
Questions
Which AAAHC standard covers allergy documentation?
CRD.210. AAAHC says allergy verification should be performed and documented 100% of the time, including the reaction and its severity.
Does AAAHC accept electronic health records?
Yes. The Clinical Records standards apply regardless of vendor or platform, with written policies on access, editing, deletion, backup and retention.
Can an AI scribe write the clinical record?
An AI tool can draft it. The clinician must review, correct and sign it, and from v45 the governing body must oversee how AI is used.
Sources
- 1AAAHC, 2026July 2026 Triangle Times Today, Electronic Health Records in Ambulatory CareRead source
- 2AAAHC, 2026April 2026 Triangle Times Today, procedure observation and the six components of a QI studyRead source
- 3AAAHC, 2026August 2026 Triangle Times Today, AAAHC's New v45 Standards Provide Guidance for Artificial Intelligence UseRead source
- 4AAAHC, 2025October 2025 Triangle Times TodayRead source
- 5AAAHC, 2026March 2026 Triangle Times Today, Artificial Intelligence, AAAHC's Framework for Responsible ImplementationRead source
Written by the wai team from Accreditation Association for Ambulatory Health Care guidance, checked on 15 October 2026. This is guidance, not legal advice. AAAHC does not endorse wai or any software.