California Code of Regulations
Title 22 - Social Security
Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies
Chapter 4 - Intermediate Care Facilities
Article 4 - Administration
Section 73547 - Content of Health Records
Universal Citation: 22 CA Code of Regs 73547
Current through Register 2024 Notice Reg. No. 52, December 27, 2024
(a) A facility shall maintain for each patient a health record which shall include the following:
(1) Diagnoses (current).
(2) Drug and treatment orders.
(3) Diet orders.
(4) Progress notes written at the time of visit by
professional personnel in attendance to the patient.
(5) Nurses' notes which shall include:
(A) Narrative notes made by nurses' aides when
appropriate, and after such aides have been properly instructed. They shall include:
1. Care and treatment done with and for the
patient.
2. Patients' reactions to care
and treatment.
3. Daily observation of
how the patient looks, feels, reacts, interacts, degree of dependency and motivation
towards improved health.
(B)
Meaningful and informative nurses' progress notes written by licensed nurses as
often as the patient's condition warrants. However, weekly nurses' progress notes
shall be written by licensed personnel on each patient and shall be specific to the
psychological, emotional, social, spiritual, recreational needs and related to the
patient care plans.
Progress notes reflecting observations of the patient's response to his environment, physical limitations, independent activities, dependency status, behavioral changes, skin problems, dietary problems and restorative measures to characterize the functional status of progression and/or regression.
(C) Name, dosage and
time of administration of drugs, the route of administration if other than oral and
site of injection. If the scheduled time is indicated on the record the initial of
the person administering the dose shall be recorded, provided that the drug is given
within one hour of the scheduled time. If the scheduled time is not recorded, the
person administering the dose shall record both his initials and the time of
administration.
(D) Justification for
and the results of the administration of all P.R.N. medications and the withholding
of scheduled medications.
(E) Record of
type of restraint and time of application and removal. The time of application and
removal shall not be required for soft tie restraints used for the support and
protection of the patient.
(F)
Medications and treatments administered and recorded as
prescribed.
(6) Current
history and physical examination or appropriate health evaluation.
(7) Temperature, pulse and respiration where
indicated.
(8) Laboratory reports of all
tests prescribed and completed.
(9)
Reports of all X-rays prescribed and taken.
(10) Condition and diagnosis of patient at time of
discharge and final disposition.
(11)
Orders provided by a licensed healthcare practitioner acting within the scope of his
or her professional licensure, including drug, treatment and diet orders signed on
each visit. Orders provided by the licensed healthcare practitioners acting within
the scope of his or her professional licensure recapitulated as
appropriate.
(12) Observation and
information pertinent to the dietetic treatment recorded in the patient's health
record by the dietitian or nurse. Pertinent dietary records shall be included in
patient's transfer records to ensure continuity of nutritional care.
(13) Consent forms for prescribed treatment and
medication.
(14) An inventory of all
patients' personal effects and valuables made upon admission and discharge. The
inventory list shall be signed by a representative of the facility and the patient
or his authorized representative with one copy to be retained by
each.
1. Amendment of subsections (a)(5)(A)3., (a)(5)(E) and (a)(11) and new NOTE filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).
Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
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