Chapter Med 21

Chapter Med 21

PATIENT HEALTH CARE RECORDS

Med 21.01   Authority and purpose.

Med 21.02   Definitions.

Med 21.03   Minimum standards for patient health care records.

Med 21.01 Med 21.01 Authority and purpose. The rules in this chapter are adopted by the board under the authority of ss. 15.08 (5) (b), 227.11 (2) and 448.40 (1), Stats., to govern the practice of physicians and physician assistants in the preparation and retention of patient health care records.

Med 21.01 History History: Cr. Register, April, 1996, No. 484, eff. 5-1-96; am. Register, December, 1999, No. 528, eff. 1-1-00.

Med 21.02 Med 21.02 Definitions. As used in this chapter:

Med 21.02(1) (1) “Board” means the medical examining board.

Med 21.02(2) (2) “Patient” means a person who receives health care services from a physician or physician assistant.

Med 21.02(3) (3) “Patient health care record” has the meaning given in s. 146.81 (4), Stats.

Med 21.02 History History: Cr. Register, April, 1996, No. 484, eff. 5-1-96; am. (2), Register, December, 1999, No. 528, eff. 1-1-00.

Med 21.03 Med 21.03 Minimum standards for patient health care records.

Med 21.03(1) (1) A physician or physician assistant shall maintain patient health care records on every patient administered to for a period of not less than 5 years after the date of the last entry, or for such longer period as may be otherwise required by law.

Med 21.03(2) (2) A patient health care record prepared by a physician or physician assistant shall contain the following clinical health care information which applies to the patient’s medical condition:

Med 21.03(2)(a) (a) Pertinent patient history.

Med 21.03(2)(b) (b) Pertinent objective findings related to examination and test results.

Med 21.03(2)(c) (c) Assessment or diagnosis.

Med 21.03(2)(d) (d) Plan of treatment for the patient.

Med 21.03(3) (3) Each patient health care record entry shall be dated, shall identify the practitioner, and shall be sufficiently legible to allow interpretation by other practitioners for the benefit of the patient.

Med 21.03 History History: Cr. Register, April, 1996, No. 484, eff. 5-1-96; am. (1) and (2) (intro.), Register, December, 1999, No. 528, eff. 1-1-00.