Duty to keep an accurate record
A licensee shall keep and maintain a record for each patient for whom the licensee has provided medical services, including a full and complete record of tests and examinations performed, observations made, and treatments provided. Where a medical service involves the vaginal or anal penetration of the patient, the licensee shall expressly state in the record that vaginal or anal penetration was performed, unless the service falls within one of the four stated exclusions. Records must be maintained so as to protect their integrity, ensure their confidentiality and proper use, and ensure their accessibility and availability to each patient or the patient's authorized representative as required by law.
What this means operationally
Michigan states the duty to create the record and the standard it must be held to in one place, and both reach every professional licensed under article 15 — so this is the baseline a dentist, optometrist, physical therapist and physician all work from. The penetration-documentation requirement is an express content rule rather than a matter of clinical style: the record must SAY that penetration was performed, and the four exclusions are narrow and defined in the statute rather than left to judgment.
Applies when
- A licensee has provided medical services to a patient
Exceptions
- The penetration-documentation requirement does not apply to services primarily relating to urological, gastrointestinal, reproductive, gynecological or sexual health; services necessary and incident to a medical emergency; rectal administration of a drug; or measuring temperature

