Mich. Admin. Code R. 325.45191

Current through Vol. 24-21, December 1, 2024

Section 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.

Mich. Admin. Code R. 325.45191

2020 MR 4, Eff. 2/21/2020