Minnesota Administrative Rules
Agency 144 - Health Department
Chapter 4658 - NURSING HOMES
MEDICAL AND DENTAL SERVICES
Part 4658.0715 - MEDICAL INFORMATION FOR CLINICAL RECORD

Universal Citation: MN Rules 4658.0715

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

Disclaimer: These regulations may not be the most recent version. Minnesota may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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