Current through February, 2024
(a) Individual
records shall be maintained for each resident. Upon admission or readmission,
the facility shall maintain:
(1) Records
which identify the resident's name, social security number, marital status,
date of birth, sex, next of kin or guardian, and religious preference, if any.
A record of the address and telephone number of the referral agency or source
by which the resident was admitted, the attending physician, dentist, and other
medical or social service professionals who are currently involved in providing
services to the resident, as well as a record of the agency responsible for
financial payment, and the medical insurance plan;
(2) A report of a medical examination current
to within nine months and current diagnosis, physician's orders for medication,
diet, special appliances and equipment, treatment, evaluations or direct
service to be provided by a physical therapist, occupational therapist, or
speech pathologist and a report of an examination for tuberculosis performed
within the year prior to admission, height and weight and medical
history;
(3) Copies of the
resident's individual plan; and
(4)
An inventory of money and valuables. This inventory shall be kept
current.
(b) During
residence, records shall be maintained by the caregiver and shall include the
following information:
(1) Copies of
physician's initial, annual and other periodic examinations, evaluations,
medical progress notes, relevant laboratory reports, and a report of
re-examination of tuberculosis;
(2)
Observations of the resident's response to medication, treatments, diet,
provision of care, response to activities programs, indications of illness or
injury, unusual skin problems, changes in behavior patterns, noting the date,
time and actions taken, if any, which shall be recorded monthly or more often
as appropriate but immediately when an incident occurs;
(3) Entries by the caregiver describing
treatments and services rendered;
(4) Medications made available;
(5) Physician's signed orders for diet,
medications, special appliances, adaptive equipment, and treatments;
(6) All recordings of temperature, pulse,
respiration as ordered by a physician or as may appear to be needed. Physicians
shall be promptly advised of any changes in physical or mental
status;
(7) Recording of resident's
weight at least once a month, and more often when requested by a
physician;
(8) Notation of visits
and consultations made to residents by other authorized personnel;
and
(9) Correspondence pertaining
to the resident's physical and mental status.
(c) Unusual incidents shall be noted in the
resident's progress notes. An incident report of any bodily injury or other
unusual circumstances affecting a resident which occurs within the home, on the
premises, or elsewhere shall be submitted to the case manager within
twenty-four hours from the time of the incident and shall be retained by the
facility under separate cover, and shall be made available to the department
and other authorized personnel. The resident's physician shall be called
immediately if medical care is necessary.
(d) When a resident is transferred, the
caregiver shall provide a written transfer summary promptly to the receiving
facility, which shall include:
(1) The reason
for the transfer;
(2) Evidence of
prior notice or the written consent of the resident's legal guardian, if
any;
(3) Current physical and
mental status of resident; and
(4)
Current diet, medication, and activity orders signed by a physician.
In the course of an emergency transfer, as much of the
information required in section 11-89-21 shall be given as time permits.
(e) General rules
regarding records:
(1) All entries in the
resident's records shall be written in blue or black ink, or typewritten, shall
be legible, dated, and signed with full signature and title by the individual
making the entry;
(2) Erasures and
white outs shall be not be permitted;
(3) Symbols and abbreviations may be used in
recording entries only if they conform to standard medical symbols or a legend
is provided to explain them;
(4) An
area shall be provided for the safe and secure storage of residents' records
which must be retained by the facility for periods as prescribed by state law;
and
(5) All records shall be
complete and current and readily available for review by the department or any
responsible placement agency.
(f) All information contained in resident's
record shall be treated by the staff as confidential. Written consent of the
resident or resident's guardian, shall be required for the release of
information to persons not otherwise authorized to receive it.
Records shall be secured against loss, destruction,
defacement, tampering, or use by unauthorized persons. There shall be written
policies governing access to, duplication of, and release of any information
from the resident's record. Records shall be readily accessible and available
to authorized department personnel for the purpose of determining compliance
with the provisions of this chapter.
(g) Miscellaneous records:
(1) A permanent general register shall be
maintained to record all admissions and discharges of residents;
(2) When requested statistical information
shall be provided to the department; and
(3) Records of evacuation drills shall be
available to the department for inspection.
