Upon presentation of a new patient, patient records shall contain the following essential elements as relevant or applicable to the evaluation and treatment of the patient:

1. (1) History of the present illness or complaints, and significant past health, medical and social history.
2. (2) Significant family medical history and health factors which may be congenital or familial in nature.
3. (3) Review of patient systems, including cardiovascular, respiratory, musculoskeletal, integumentary and neurologic.
4. (4) Results of physical examination and diagnostic testing focusing on areas pertinent to the patient’s chief complaints.
5. (5) Assessment or diagnostic impression of the patient’s condition.
6. (6) Treatment plan for the patient, including all treatments rendered, and all other ancillary procedures or services rendered or recommended.

History

History: Cr. Register, May, 1997, No. 497, eff. 6-1-97.