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Medical Records Collection, Retention, and Access in Michigan

Under Michigan law, a physician must keep a patient’s records for at least seven years after the patient’s last visit.1 Similarly, Michigan law requires healthcare facilities to maintain complete and accurate records on all patients for at least seven years from a patient’s last visit.2  Failure of either a physician or healthcare facility to comply with these rules may result in a fine.3  Mental health providers are required to maintain medical records for each of their patients receiving mental health services.4  Hospitals are required to adopt policies and procedures regarding maintenance of patient medical records.5  The state also requires all health care providers to have policies and procedures in place for the maintenance of medical records and providing access to medical records.6  Similarly, a health care facility is required to contract with another entity if it cannot maintain its own medical records.7

 

Michigan law also mandates that insurance companies maintain clinical patient records. If the patient receives inpatient treatment, then the healthcare facility is responsible to keep the patient’s medical record and provide it to the insurance company if needed.8

 

Michigan law also specifies the content of medical records.  Physicians must record a patient’s informed consent in the medical record.9  The state has specific informed consent requirements for different procedures and treatments, including abortions,10 breast cancer treatments, 11 and genetic testing, that must be recorded in the patient’s medical record.12  Hospital records must include basic clinical information about the patient, and more specific information if the patient has surgery.13  The contents of insurers’ clinical records are also specified by law.  An insurer’s clinical record must include identification information, medical evaluations, diagnostic information, and any other supporting documentation.14

 

Michigan law allows patients access to their medical records by sending a written request for access to the health care provider.15  Patients are given broad access to their medical records in the state of Michigan.  Patients have the right to inspect, copy, and access their medical records from health care facilities.16 If an individual wishes to review his records maintained by the State Department of Public Health, then the individual must submit a request in writing for his records.17 Healthcare providers cannot inquire into a patient’s request for medical records.18 However, healthcare providers, including health care facilities can charge a fee for a patient’s request for a copy of his record.19

 

Footnotes

  • 1. M.C.L.A. §333.16213
  • 2. M.C.L.A. §333.20175
  • 3. M.C.L.A. §333.16213; M.C.L.A. §333.20175
  • 4. M.C.L.A. § 330.1141
  • 5. M.C.L.A. §331.161
  • 6. M.C.L.A. §333.16177
  • 7. M.C.L.A. §333.20175a
  • 8. MI ADC R. 325.6801
  • 9. M.C.L.A. § 333.5657
  • 10. M.C.L.A. §333.17015
  • 11. M.C.L.A. §333.17013
  • 12. M.C.L.A. §333.17520
  • 13. MI ADC R. 325.1028
  • 14. MI ADC R. 325.6805
  • 15. M.C.L.A. §333.26265
  • 16. M.C.L.A. §333.20201
  • 17. M.C.L.A. §333.2639
  • 18. M.C.L.A. §333.26267
  • 19. M.C.L.A. §333.26269; M.C.L.A. §333.2641

 

Medical Records Collection, Retention, and Access in Michigan

Subtopic Statute/Regulation Description
Content of medical record Mich. Admin. Code r. 325.1028 - Records The hospital is required to keep complete and accurate medical records on each patient.  The record must include the following: Admission...
Mich. Admin. Code r. 325.1058 - Mothers’ records Hospitals must maintain medical records for all new mothers. The records must contain information related to complications with past births and to...
Mich. Admin. Code r. 325.14419 - Client records All patient records must be retained for 3 years following the end of services. The medical records must contain a signed consent form, the date of...
Mich. Admin. Code r. 325.14603 - Client records All clients referred for substance use disorder services must have medical records. The medical records must include, at a minimum, the client’...
Mich. Admin. Code r. 325.14705 - Treatment plans Patients receiving mental health and substance use treatments must be provided with a treatment plan. The attending physician must assess the patient...
Mich. Admin. Code r. 325.14711 - Maintenance of client records Every patient receiving treatment for mental health or substance abuse must have a medical record that includes the results of examinations and tests...
Mich. Admin. Code r. 325.165 - Amendment, replacement, and removal of records A provider may amend information in the registry so long as they provide the correct authorization code and include the replacement information on...
Mich. Admin. Code r. 325.1942 - Resident records All nursing homes must maintain medical records for each resident. The records must include the following: Identifying information; Contact...
Mich. Admin. Code r. 325.20406 - Patient bill of rights provisions All nursing homes must comply with the Patient’s Bill of Rights. All information that the nursing home provides to the patient must be given in...
Mich. Admin. Code r. 325.3831 - Records All surgical centers must maintain patient medical records. The facilities must also maintain administrative records, including information about...
Mich. Admin. Code r. 325.3847 - Medical records Any patient undergoing surgery must have a medical record that is signed by the attending physician. The hospital-operated facility must maintain...
Mich. Admin. Code r. 325.6801 - Clinical patient records; medical records service; record administrator or technician An insurance company is required to maintain a clinical patient record.  For treatment provided on an inpatient basis, the responsibility is on...
Mich. Admin. Code r. 325.6805 - Clinical patient records; contents; entries; organization; reports The insurance company should ensure there is a unit clinical record for each patient.  The record must include the following: 1) An...
Mich. Comp. Laws Ann. § 330.1141 - Record of patient All licensed mental health providers must keep a medical record for each patient receiving mental health services that contains, at minimum, a...
Mich. Comp. Laws Ann. § 330.1717 - Electroconvulsive therapy or other procedure; consent Michigan prohibits the administration of “electroconvulsive therapy or a procedure intended to produce convulsions or coma” without...
Mich. Comp. Laws Ann. § 330.1723 - Suspected abuse of recipient or resident; report to law enforcement agency All records listing the identity, diagnosis, prognosis, and treatment of a patient being treated for substance use disorder are confidential....
Mich. Comp. Laws Ann. § 330.1740 - Physical restraint Michigan permits the use of physical restraints within a mental health facility in limited circumstances. Such restraints are proper only if “...
Mich. Comp. Laws Ann. § 330.1746 - Record All patients receiving mental health services must have a clinical record that includes, at a minimum, information related to the services provided...
Mich. Comp. Laws Ann. § 333.1058 - Copy of order as permanent medical record A physician must place a copy or duplicate of a do-not-resuscitate order in the patient’s medical record immediately after the patient executes...
Mich. Comp. Laws Ann. § 333.1060 - Revocation of order Revocation of order   If a patient revokes their do-not-resuscitate order, a physician must immediately place the revocation and a writing that...
Mich. Comp. Laws Ann. § 333.16177 - License or registration; form of application; inclusion of social security number; examination; passing scores; additional information; exception to social security requirement Michigan requires providers applying for or renewing their license to submit an affidavit declaring that they have a “written policy for...
Mich. Comp. Laws Ann. § 333.1716 - Surgery; consent A mental health patient must give informed consent, either directly or through a third-party, prior to any surgeries. Informed consent must come in...
Mich. Comp. Laws Ann. § 333.17745 - Regulations and guidelines regarding the dispensation of drugs by prescribers Any prescriber dispensing prescription drugs must have a drug control license for each location that they are storing and dispensing prescription...
Mich. Comp. Laws Ann. § 333.17752 - Prescription or equivalent record; preservation; disclosure; providing copies; refilling copy; applicability of subsection (3) to pharmacies sharing real-time, on-line database A dispenser must maintain a prescription record for each prescription drug dispensed to a patient and must retain the records for no less than 5...
Mich. Comp. Laws Ann. § 333.20821 - Freestanding surgical outpatient facility; requirements All freestanding surgical outpatient facilities must: Be able to provide major and minor surgical procedures; Have the necessary staff and...
Mich. Comp. Laws Ann. § 333.21773 - Guidelines and regulations regarding the involuntary transfer or discharge of patients by nursing homes As a general rule, Michigan prohibits nursing homes from involuntarily discharging or transferring patients, but Michigan does provide certain...
Retention periods Mich. Admin. Code r. 325.14419 - Client records All patient records must be retained for 3 years following the end of services. The medical records must contain a signed consent form, the date of...
Mich. Admin. Code r. 325.14711 - Maintenance of client records Every patient receiving treatment for mental health or substance abuse must have a medical record that includes the results of examinations and tests...
Mich. Admin. Code r. 325.177 - Provision of care by local health departments for venereal disease; maintenance of test records after provision of pregnancy care All local health departments must diagnose and treat venereal disease cases. The local health departments must treat all individuals regardless of...
Mich. Admin. Code r. 325.1942 - Resident records All nursing homes must maintain medical records for each resident. The records must include the following: Identifying information; Contact...
Mich. Admin. Code r. 325.6810 - Clinical patient records; confidentiality; disclosure; availability; storage and preservation Information from a patient’s clinical record in the possession of an insurance company is confidential and can only be disclosed to authorized...
Mich. Comp. Laws Ann. § 333.16213 - Retention of records Retention of records   All patient records are considered to be the property of and are held in the custody of the health care provider. A...
Mich. Comp. Laws Ann. § 333.17745 - Regulations and guidelines regarding the dispensation of drugs by prescribers Any prescriber dispensing prescription drugs must have a drug control license for each location that they are storing and dispensing prescription...
Mich. Comp. Laws Ann. § 333.17752 - Prescription or equivalent record; preservation; disclosure; providing copies; refilling copy; applicability of subsection (3) to pharmacies sharing real-time, on-line database A dispenser must maintain a prescription record for each prescription drug dispensed to a patient and must retain the records for no less than 5...
Mich. Comp. Laws Ann. § 333.5114a - Referral of HIV infected individual to local health department; obligations of the local health department Referral of individual to local health department; assistance with partner notification; information; legal obligation to inform sexual partners;...
Destruction, storage and filing of medical records (Cross reference with Security of Health Information) Mich. Admin. Code r. 325.14711 - Maintenance of client records Every patient receiving treatment for mental health or substance abuse must have a medical record that includes the results of examinations and tests...
Mich. Admin. Code r. 325.6810 - Clinical patient records; confidentiality; disclosure; availability; storage and preservation Information from a patient’s clinical record in the possession of an insurance company is confidential and can only be disclosed to authorized...
Mich. Admin. Code r. 500.554 - Objectives of information security program The insurer or health plan’s information security program must ensure the security and confidentiality of consumer information, protect against...
Mich. Comp. Laws Ann. § 333.16213 - Retention of records Retention of records   All patient records are considered to be the property of and are held in the custody of the health care provider. A...
Mich. Comp. Laws Ann. § 400.111b - Requirements as condition of participation by provider As a condition of participation to provide Medicaid services, a provider must meet the following requirements: Comply with all state licensing...
Mich. Comp. Laws Ann. § 550.1406 - Regulations and guidelines regarding health care companies' protection of members' privacy All health care corporations must use reasonable care when securing patients’ medical records to ensure the confidentiality of the information...
Mich. Comp. Laws Ann. § 750.492a - Placing misleading or inaccurate information in medical records or charts; alteration or destruction of medical records or charts; penalties Placing misleading or inaccurate information in medical records or charts; alteration or destruction of medical records or charts; penalties;...
Required maintenance of medical records Mich. Admin. Code r. 325.165 - Amendment, replacement, and removal of records A provider may amend information in the registry so long as they provide the correct authorization code and include the replacement information on...
Mich. Admin. Code r. 325.6801 - Clinical patient records; medical records service; record administrator or technician An insurance company is required to maintain a clinical patient record.  For treatment provided on an inpatient basis, the responsibility is on...
Mich. Comp. Laws Ann. § 330.1141 - Record of patient All licensed mental health providers must keep a medical record for each patient receiving mental health services that contains, at minimum, a...
Mich. Comp. Laws Ann. § 331.161 - Board of trustees; hospital operation rules, records, denial of privileges to physicians The board of a hospital will establish rules and regulations pertaining to items such as “conduct and maintenance of proper medical records....
Mich. Comp. Laws Ann. § 333.20175 - Regulations and guidelines regarding patient records; regulations and guidelines regarding disciplinary actions against health professionals The hospital must require that complete and accurate medical records be kept on all patients.  The record must be kept for at 7 years from the...
Mich. Comp. Laws Ann. § 333.20175a - Agreement with another health facility to protect, maintain, and provide access to records; closure of health facility; noncompliance; fine; definitions Maintaining record for each patient; confidentiality; wrongfully altering or destroying records; noncompliance; fine; licensing and certification...
Right to access to medical records (Access by representative or other person authorized by the patient through informed consent; copying fees, or other requirements (e.g., requirement to give patient access in electronic format)) Mich. Admin. Code r. 325.3847 - Medical records Any patient undergoing surgery must have a medical record that is signed by the attending physician. The hospital-operated facility must maintain...
Mich. Comp. Laws Ann. § 330.1448 - Right to copy of certain documents; explanation in individual's language; consent to treatment by person awaiting hearing; form Within 12 hours of voluntary or involuntary hospitalization for treatment of a mental illness, a hospital director must furnish the individual with a...
Mich. Comp. Laws Ann. § 333.1060 - Revocation of order Revocation of order   If a patient revokes their do-not-resuscitate order, a physician must immediately place the revocation and a writing that...
Mich. Comp. Laws Ann. § 333.17013 - Alternative methods of treatment of breast cancer; duty of physician to inform patient; standardized written summary or brochure; form; civil action A physician administering primary treatment for breast cancer must provide their patient with information, both orally and in writing, about...
Mich. Comp. Laws Ann. § 333.17015 - Guidelines and regulations regarding abortion Informed consent; definitions; duties of physician or assistant; location; disclosure of information; view of ultrasound; medical emergency...
Mich. Comp. Laws Ann. § 333.17520 - Genetic test; informed consent Genetic test; informed consent   Physicians must obtain a patient’s written, informed consent before performing a presymptomatic or...
Mich. Comp. Laws Ann. § 333.17752 - Prescription or equivalent record; preservation; disclosure; providing copies; refilling copy; applicability of subsection (3) to pharmacies sharing real-time, on-line database A dispenser must maintain a prescription record for each prescription drug dispensed to a patient and must retain the records for no less than 5...
Mich. Comp. Laws Ann. § 333.20175a - Agreement with another health facility to protect, maintain, and provide access to records; closure of health facility; noncompliance; fine; definitions Maintaining record for each patient; confidentiality; wrongfully altering or destroying records; noncompliance; fine; licensing and certification...
Mich. Comp. Laws Ann. § 333.20201 - Policy describing rights and responsibilities of patients or residents A health facility or health care center must post a policy describing the rights and responsibilities of patients in a public place.  The policy...
Mich. Comp. Laws Ann. § 333.26265 - Request by authorized individual to examine or obtain medical record; response by health care provider or facility; extension of response time Michigan grants patients and their representatives a right to access the patient’s medical records, but limits this right in certain...
Mich. Comp. Laws Ann. § 333.26267 - Inquiry as to purpose prohibited A physician or hospital cannot ask a patient about the reason for the request of his or her medical record. 
Mich. Comp. Laws Ann. § 333.26269 - Fee A health care provider or facility can charge a patient or his/her authorized representative a fee for a copy of his/her medical record.  The...
Mich. Comp. Laws Ann. § 333.2639 - Review of personal records upon request; procedures for reviewing request; administrative hearing; records of requests An individual has the right to review his or her own personal records maintained by the State Department of Public Health if the individual submits...
Mich. Comp. Laws Ann. § 333.2641 - Fees; disposition of collections The State Department of Public Health can charge reasonable fees to patients who seek to review and have copies of their personal records.  The...
Mich. Comp. Laws Ann. § 333.2881 - Procedures applicable to system of vital statistics; request and fee for verification of facts; request and fee for name and location of court which finalized adoption The Department of Public Health must maintain the confidentiality of all records related to vital records, and must regulate the disclosure of data...
Mich. Comp. Laws Ann. § 333.5657 - Availability of form to patient, patient surrogate, or patient advocate; compliance with MCL 333.5656; placement of signed form in patient's medical record; signed form as bar to civil or administrative action A physician complies with their informed consent duties by providing a “standardized, written summary” regarding a patient’s...
Mich. Comp. Laws Ann. § 52.202 - Investigation by county medical examiner as to cause and manner of death; prisoners; medical records, papers, or documents; exemption from disclosure; definitions A medical examiner must investigate the cause of death whenever an individual dies violently, unexpectedly, without medical supervision, following an...
Mich. Comp. Laws Ann. § 700.5508 - Determination of advocate's authority to act A patient advocate may only make decisions on behalf of the patient when a physician or psychologist determines that the patient is “unable to...