Section 21.03. Minimum standards for patient health care records.

 

(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.

(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:

(a) Pertinent patient history.

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

(c) Assessment or diagnosis.

(d) Plan of treatment for the patient.

(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.

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