California Code of Regulations
Title 22 - Social Security
Division 7 - Health Planning and Facility Construction
Chapter 12 - Postsurgical Recovery Care Demonstration Project
Article 2 - Required Services
Section 97510.17 - Nurses' Notes
Universal Citation: 22 CA Code of Regs 97510.17
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Nurses' notes shall be kept for all patients and included in the patients' records.
(b) Nurses' notes shall include, but not be limited to, the following:
(1) A concise and accurate record of nursing care administered.
(2) A record of pertinent observations including psychosocial and physical manifestations as well as incidents and unusual occurrences, and relevant nursing interpretation of such observations.
(3) Name, dosage, time, and route of administration of medications and treatment. If administration is by injection, site of injection shall be recorded.
(4) Record of vital signs.
1. New section filed 3-7-88 as an emergency; operative 3-7-88 (Register 88, No. 12). No Certificate of Compliance required pursuant to the provisions of Health and Safety Code section 1250.9(m).
2. Editorial correction of HISTORY No. 1 (Register 90, No. 21).
Note: Authority cited: Section 1250.9, Health and Safety Code. Reference: Section 1250.9, Health and Safety Code.
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