Wisconsin Administrative Code
Medical Examining Board
Chapter Med 21 - Patient health care records
Section Med 21.03 - Minimum standards for patient health care records
Universal Citation: WI Admin Code ยง Med 21.03
Current through August 26, 2024
(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.
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