Mich. Admin. Code R. 330.1276

Current through Vol. 24-22, December 15, 2024

Section R. 330.1276 - Records

Rule 1276.

(1) All of the following records shall be maintained by a licensee and shall be made available for examination by the department:

(a) Policies and procedures followed by the hospital to ensure that employees are in good physical and mental health.

(b) Documentation which substantiates that the policies and procedures specified in subdivision (a) have been uniformly implemented.

(c) Records of periodic inspection by local and state fire marshals.

(d) Records of execution of fire and simulated disaster plan drills.

(e) Records of health inspections, including both of the following:

(i) Inspections by state or local health authorities.

(ii) Documentation of actions taken to comply with department of public health recommendations.

(f) Reports of the joint commission on accreditation of hospitals, including both of the following:

(i) Notification of accreditation and a list of recommendations.

(ii) Notification of disapproval and a list of recommendations.

(2) All of the following administrative records shall be maintained by a licensee and shall be made available for examination by the department:

(a) Admissions, discharges, transfers, and deaths.

(b) All of the following complete and accurately written records:

(i) Personnel policies and procedures.

(ii) Job descriptions.

(iii) Personnel assignments.

(c) Written policies and procedures relating to the notification of responsible persons in the event of a significant change in the physical or mental condition of a patient.

(d) Records of all of the following:

(i) Unusual deaths of patients.

(ii) Unusual behavior of, or incidents regarding, patients.

(iii) Accidents or injuries.

(e) Patient movement in and out of the hospital.

(3) A licensee shall maintain an adequate medical record for every patient in the hospital, which shall include all of the following information:

(a) Identification data and consent forms.

(b) History of the patient.

(c) All of the following reports:

(i) Psychiatric evaluations.

(ii) Neurological and physical examinations.

(iii) Other diagnostic procedures and examinations.

(d) Individualized plan of services.

(e) Medical orders.

(f) Observations.

(g) Reports of actions, findings, and conclusions.

(h) Discharge summary.

(4) Medical records shall be confidential, as required by section 748 of the act, and shall be current and accurate.

(5) A registered record administrator or an accredited record technician shall be employed on a full-time or part-time basis to facilitate accurate processing, checking, indexing, and filing of medical records.

(6) The medical record services shall maintain a system of identification and filing to facilitate prompt location of a patient's medical records.

Mich. Admin. Code R. 330.1276

1979 AC; 1986 AACS; 1988 AACS