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Mich. Admin. Code r. 325.1028 - Records
Link to the law
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Current as of June 2015
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The hospital is required to keep complete and accurate medical records on each patient. The record must include the following:
- Admission date;
- Diagnosis at the time of admission;
- History;
- Physician’s notes;
- Physician’s orders;
- Nurse’s notes, including temperature, pulse, conditions and medications;
- Record of discharge or death;
- Final diagnosis.
Patients who have surgery must have in their records:
- Details about their preoperative diagnosis;
- Preoperative medicine;
- Name of the surgeon;
- Method and amount of anesthesia;
- Name of anesthesiologist;
- Post operative diagnosis and findings.
Special reports such as x-rays and pathology reports should be included in the patient’s medical record.
Current as of June 2015
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