1. (1) When patient healthcare records are not maintained by a separate entity, a physician assistant shall ensure patient health care records are maintained on every patient for a period of not less than 5 years after the date of the last entry, or for a longer period as may be otherwise required by law.

2. (2) A patient health care record shall contain all of the following clinical health care information which applies to the patient’s medical condition:

   1. (a) Pertinent patient history.
   2. (b) Pertinent objective findings related to examination and test results.
   3. (c) Assessment or diagnosis.
   4. (d) Plan of treatment for the patient.
3. (3) Each patient health care record entry shall be dated, shall identify the physician assistant, and shall be sufficiently legible to allow interpretation by other health care practitioners.

History

History: EmR2206: cr., eff. 4-1-22; CR 22-064: cr. Register July 2023 No. 811, eff. 8-1-23.