A.
Medical Records. A medical record shall be developed at the time the child is
accepted at the PDHC facility and maintained throughout the facility's care of
the child.
1. The record shall be signed by
authorized personnel and shall contain at least the following documents:
a. a medical plan of treatment and a nursing
plan of care;
b. the referral and
admission documents concerning the child;
d. medical history, including allergies and
special precautions;
e.
documentation of immunizations;
f.
medication/treatment administration record;
g. concise, accurate information and
initialed case notes reflecting progress toward achievement of care goals or
reasons for lack of progress;
h.
documentation of nutritional management and therapeutic diets, as
appropriate;
i. documentation of
physical, occupational, speech and other special therapies;
j. correspondence and other documents
concerning the child;
k. an order
written by the prescribing physician if the child terminates services with the
facility, if applicable; and
l. a
summary, including the reason why the child is terminating services with the
facility, if applicable.
2. The medical records shall contain the
individualized nursing care plan that shall be developed within 10 working days
of the child's acceptance to the PDHC facility.
a. The nursing care plan shall be reviewed
and revised quarterly, or more frequently as necessary. The nursing care plan
shall include any recommendations and revisions to the care plan based on
consultation with other professionals involved in the child's care.
3. The plan of care, telephone
and/or verbal orders shall be signed by the physician within a timely manner,
not to exceed 30 days.
a. The physician's
verbal orders may be accepted by a registered nurse, a qualified therapist or a
licensed practical nurse as authorized by state and federal laws and
regulations.
b. Verbal orders taken
by an LPN shall be cosigned by an RN or appropriate therapist.
c. Electronic physician signatures may be
accepted per PDHC facility policies.
d. Stamped physician signatures shall not be
accepted.
4. All medical
and patient records shall be maintained by the PDHC facility in accordance with
federal and state law,rule, and regulation regarding confidentiality, privacy
and retention.
