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Mich. Admin. Code r. 325.1028 - Records

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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