(A) Each facility
shall develop, through an interdisciplinary team, and adopt written policies
and procedures to ensure complete and accurate clinical records are maintained
for each resident and readily available as needed, including to the resident
and his or her guardian and other providers as permitted by law or authorized
by the resident or his or her guardian prior to submitting an application for a
license. Each facility shall implement, review and revise, through an
interdisciplinary team as needed, but not less than once a year, its written
policies and procedures. A facility shall ensure all staff, including temporary
staff and volunteers, are trained and determined to be competent as needed for
their duties on such policies and procedures.
(B) All records shall be complete, accurate,
current, available on the premises of the facility. In addition to the clinical
record for each resident, the following records shall be maintained:
(1) Daily census;
(2) Resident care policies;
(3) Incident, fire, epidemic, emergency and
other report forms;
(4) Schedules
of names, telephone numbers, dates and alternates for all emergency or "on
call" personnel;
(5) A Resident
Roster approved by the Department;
(6) Orders for all medications, treatments,
diets, rehabilitation services and medical procedures ordered for residents.
Orders shall be dated, recorded and signed (telephone orders countersigned) by
the resident's primary care provider. If electronic signatures are permitted,
the facility must ensure their system is designed to ensure integrity,
authenticity and non-repudiation;
(7) A record of narcotic and
sedatives;
(8) A bound Day and
Night Report Book with a stiff cover and numbered pages, or electronic record
of reports with an audit trail;
(9)
Identification and summary sheets on all residents;
(10) In a SNCFC, an Individual Service Plan
(ISP) shall be developed for each resident.
(C) All facilities shall maintain a separate,
complete, accurate and current clinical record in the facility for each
resident from the time of admission to the time of discharge. This record shall
contain all medical, nursing and other related data. All entries shall be dated
and signed. The clinical record shall include:
(1)
Identification and Summary
Sheet including: resident's name, bed and room number, social
security number, age, sex, race, marital status, religion, home address, and
date and time of admission; names, addresses and telephone numbers of primary
care provider and alternates, of referring agency or institution, and of any
other practitioner attending the resident (dentist, podiatrist); name, address
and telephone number of emergency contact; admitting diagnosis, final
diagnosis, and associated conditions on discharge; and placement. In a SNCFC,
the data shall include the name, address and telephone number of the parent or
guardian.
(2)
A Health
Care Referral Form, Hospital Summary Discharge Sheets and other
such information transferred from the agency or institution to the receiving
facility.
(3)
Admission
Data recorded and signed by the admitting nurse or responsible
person including how admitted (ambulance, ambulation or other); referred by
whom and accompanied by whom, date and time of admission; complete description
of resident's condition upon admission, including vital signs on all admissions
and weight (if ambulatory); and date and time the resident's primary care
provider was notified of the admission. In a SNCFC, all residents including
non-ambulatory residents shall have height and weight recorded upon
admission.
(4)
Initial
Medical Evaluation and medical care plan including medical
history, physical examination, evaluation of mental and physical condition,
diagnoses, orders and estimation of immediate and long-term health needs dated
and signed by the resident's primary care provider.
(5)
Primary Care Provider's
Progress Notes including significant changes in the resident's
condition, physical findings and recommendations recorded at each visit, and at
the time of periodic reevaluation and revision of medical care plans.
(6)
Consultation
Reports including consultations by all medical, psychiatric,
dental or other professional personnel who are involved in resident care and
services. Such records shall include date, signature and explanation of the
visit, findings, treatments and recommendations.
(7)
Medication and Treatment
Record including date, time, dosage and method of administration
of all medications; date and time of all treatments; special diets;
rehabilitation services and special procedures for each resident, dated and
signed by the nurse or individual who administers the medication or
treatment.
(8)
A
Record of all fires and all incidents involving
residents.
(9) A
Nursing Care Plan for each resident.
(10)
Nurses Notes
containing accurate reports of all factors pertaining to the resident's needs
or special problems and the overall nursing care provided.
(11)
Initial Plans
and written evidence of periodic review and revision of dietary, social
service, rehabilitation services, activity, and other resident care
plans.
(12)
Laboratory
and X-ray Reports.
(13) A list of each resident's clothing,
personal effects, valuables, funds or other property.
(14)
Discharge or Transfer
Data including a dated, signed primary care provider's order for
discharge; the reason for discharge and a summary of medical information,
including physical and mental condition at time of discharge; a complete and
accurate health care referral form; date and time of discharge; address of
home, agency or institution to which discharged; accompanied by whom; and
notation as to arrangements for continued care or follow-up.
(15)
Utilization Review Plan,
Minutes, Reports and Special Studies as described in
105 CMR
150.014.
(D) All clinical records of residents
including those receiving outpatient rehabilitation services shall be completed
within two weeks of discharge and filed and retained for at least five years.
Provisions shall be made for safe keeping for at least five years of all
clinical records in the event the facility discontinues operation, and the
Department shall be notified as to the location of the records and the person
responsible for their maintenance.
(E) All information contained in clinical
records shall be treated as confidential and shall be disclosed only to
authorized persons.
