Mich. Admin. Code R. 325.45193 - Surgical patient record; required information; informed consent
Rule 193.
(1) In
addition to R 325.45191, a freestanding surgical outpatient facility and a
hospital shall keep and maintain in the surgical patient record all of the
following:
(a) Name of the surgeon.
(b) Name of the anesthesiologist or
anesthetist, if other than the surgeon, if applicable.
(c) Preoperative study and diagnosis details
if medically necessary.
(d)
Provider notes including preoperative and postoperative vital signs and other
relevant observations to document the patient's stabilized condition at the
time of discharge.
(e) Product name
and dosage of any sedative and anesthetic used.
(f) Method of anesthesia and any pertinent
information concerning results or reactions.
(g) Operation and treatment notes and
consultations.
(h) The
postoperative diagnosis, including pathological findings.
(i) Social or social service information
relevant to the case.
(j) Surgeon's
operative note including all of the following:
(i) Name of each procedure
performed.
(ii) Duration of
procedure and any unusual problems or occurrences encountered.
(iii) Surgeon's description of gross
appearance of any tissues removed.
(k) Summary of instructions given for
follow-up observation and care.
(2) The facility shall obtain informed
consent from a patient, or the responsible relative or guardian in the case of
an unemancipated minor, before the performance of a surgical procedure and
maintain the signed written consent form or forms in the patient's
record.
Notes
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No prior version found.