Minnesota Administrative Rules
Agency 144 - Health Department
Chapter 4658 - NURSING HOMES
MEDICAL AND DENTAL SERVICES
Part 4658.0715 - MEDICAL INFORMATION FOR CLINICAL RECORD
Current through Register Vol. 49, No. 13, September 23, 2024
A physician or physician designee must provide the following information for the clinical record:
A. the report of the admission history and physical examination;
B. the admitting diagnosis;
C. a description of the general medical condition, including disabilities and limitations;
D. a report of subsequent physical examinations;
E. instructions relative to the resident's total program of care;
F. written orders for all medications with stop dates, treatments, rehabilitations, and any medically prescribed special diets;
G. progress notes;
H. any advanced directives; and
I. condition on discharge or transfer, or cause of death.
Statutory Authority: MS s 144A.04; 144A.08; 256B.431