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Michigan Administrative Code (Last Updated: November 16, 2016) |
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Department LR. Licensing and Regulatory Affairs |
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Bureau of Community and Health Systems |
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Chapter Minimum Standards for Hospitals |
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Part 3. OPERATIONAL RULES AND MINIMUM STANDARDS FOR ALL HOSPITAL PHYSICAL PLANT, FACILITIES, EQUIPMENT, AND |
Section 325.1028. Records.
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(1) The hospital shall require that accurate and complete medical records be kept on all patients admitted.
(2) Patients' records shall include the following:
(a) Admission date.
(b) Admitting diagnosis.
(c) History and physical examination.
(d) Physician's progress notes.
(e) Operation and treatment notes and consultations.
(f) The physician's orders.
(g) Nurse's notes including temperature, pulse, respiration, conditions observed and medication given.
(h) Record of discharge or death.
(i) Final diagnosis.
(3) Additional records of patients having surgery shall include the following:
(a) Details of the preoperative study and diagnosis.
(b) The preoperative medication.
(c) The name of the surgeon and his assistants.
(d) The method of anesthesia.
(e) The amount of anesthetic when measurable.
(f) ) The name of the anesthetist.
(g) The postoperative diagnosis, including pathological findings.
(4) The report of special examinations, such as laboratory, x-ray and pathology, shall be kept in the patient's record.
(5) Medical records shall be preserved as original records, abstracts, microfilms or otherwise and shall be such as to afford a basis for a complete audit of professional information.
(6) The administrative records of the hospital shall include as a minimum:
(a) Records of admissions and discharges.
(b) Patient's records.
(c) Daily census records.
(d) Narcotic register.
(e) Statistics regarding number of deaths.
(f) Statistics regarding number of autopsies.
History: 1954 AC; 1979 AC.