Content of Hospital Medical Records - 10-144-112 Me. Code R. § XII.E

All information contained in a patient’s hospital medical record must be authenticated, pertinent and timely.  There must be enough information in the record to sufficiently identify the patient.  Items such as discharge instructions, consultations, progress notes, initial plans of care and provisional diagnoses must be included in the record.  Additionally, each medical record must document whether the patient has executed an advanced directive, such as a living will or medical power of attorney.