Mich. Admin. Code r. 325.6805 - Clinical patient records; contents; entries; organization; reports

Rescinded November 10, 2015. 

The insurance company should ensure there is a unit clinical record for each patient.  The record must include the following:

1) An identification sheet, which includes the name, date of birth, sex, and emergency contact;

2) An initial medical evaluation that includes the patient’s past medical history, personal history, family medical history, and the results of a basic physical exam;

3) Lab reports and x-rays;

4) Consultation reports;

5) Discharge summaries from hospitals;

6) Doctor’s notes documenting each visit by the patient;

7) Drug reactions, including allergies and past vaccinations.

Each entry in a patient’s clinical record must be signed by the physician who provided the treatment.  The insurance company must ensure that the record is organized and complete.  The insurance company must add any inpatient service or external referral within 60 days of the treatment.