Mich. Admin. Code R. 325.45191 - Patient record; required information
Rule 191.
(1) A
health facility or agency shall keep and maintain a record for each patient in
compliance with sections 20175 and 20175a of the code, MCL 333.20175 and
333.20175a.
(2) The patient record
must include, as a minimum, all of the following:
(a) Patient identification, including name,
address, and birthdate.
(b)
Admission date or date services are initiated.
(c) Information submitted by a referral
source, if any.
(d) Admitting
diagnosis.
(e) Medical history and
physical examination.
(f) Clinical
diagnostic tests and findings.
(g)
Physician and other health professional orders.
(h) Health professional progress
notes.
(i) Medication and treatment
records.
(j) Notes and observations
by other personnel providing care.
(k) Final diagnosis, including pathological
findings if any.
(l) Record of
discharge, transfer, or death.
(m)
Patient designated representative for care, if applicable, and emergency
contact information.
(n) Consent
forms as required and appropriate.
Notes
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