Current through Register Vol. 35, No. 6, March 26, 2024
Except for persons admitted for short-term care, each
resident's medical record shall contain:
A.
Identification and summary
sheet:
B.
Physician's
documentation:
(1) An admission medical
evaluation by a physician, including:
(a) a
summary of prior treatment;
(b)
current medical findings;
(c)
diagnosis at the time of admission to the facility;
(d) the resident's rehabilitation
potential;
(e) the results of the
required physical examination;
(f)
level of care.
(2) All
physician's orders including:
(a) admission to
the facility;
(b) medications and
treatments;
(c) diets;
(d) rehabilitative services;
(e) limitations on activities;
(f) restraint orders;
(g) discharge or transfer orders.
(3) Physician progress notes
following each visit.
(4) Annual
physical examination.
(5) Alternate
visit schedule, and justification for such alternate visits, not to exceed 90
days.
C.
Nursing
service documentation:
(1) An
assessment of the resident's nursing needs.
(2) Initial nursing care plan and any
revisions.
(3) Nursing notes are
required as follows:
(a) for residents
requiring skilled care, a narrative nursing note shall be required as often as
needed to document the resident's condition, but at least weekly; and
(b) for residents not requiring skilled care,
a narrative nursing note shall be required as often as needed to document the
resident's condition, but at least monthly.
(4) In addition to the nursing care plan,
nursing documentation describing:
(a) the
general physical and mental condition of the resident, including any unusual
symptoms or actions;
(b) all
incidents or accidents including time, place, injuries or potential
complications from injury or accident, details of incident or accident, action
taken, and follow-up care;
(c) the
administration of all medications, the need for PRN medications and the
resident's response, refusal to take medication, omission of medications,
errors in the administration of medications, and drug reactions;
(d) food intake, when the monitoring of
intake is necessary;
(e) fluid
Intake when monitoring of intake is necessary;
(f) any unusual occurrences of appetite or
refusal or reluctance to accept diets;
(g) summary of restorative nursing measures
which are provided;
(h) summary of
the use of physical and chemical restraints;
(i) other non-routine nursing care
given;
(j) the condition of a
resident upon discharge; and
(k)
the time of death, the physician called, and the person to whom the body was
released.
D.
Social services records:
(1) a
social history of the resident; and
(2) notes regarding pertinent social data and
action taken.
E.
Activities records: Documentation of activities programming, a
history and assessment, a summary of attendance, and quarterly progress
notes.
F.
Rehabilitative
services:
(1) An evaluation of the
rehabilitative needs of the resident.
(2) Plan of treatment.
(3) Progress notes detailing treatment given,
evaluation, and progress.
G.
Dietary assessment: Record of
the dietary assessment.
H.
Dental services: Summary of all dental services resident has
received.
I.
Diagnostic
services: Records of all diagnostic tests performed during the
resident's stay in the facility.
J.
Plan of care: Plan of care which includes integrated program
activities, therapies and treatments designed to help each resident achieve
specific goals as developed by an interdisciplinary team.
K.
Authorization or consent: A
photocopy of any court order, power of attorney or living will authorizing
another person to speak or act on behalf of the resident and any resident
consent forms.
L.
Discharge
or transfer information: Documents, prepared upon a resident's discharge
or transfer from the facility, summarizing, when appropriate:
(1) current medical finding and
condition;
(2) final
diagnosis;
(3) rehabilitation
potential;
(4) a summary of the
course of treatment;
(5) nursing
and dietary information;
(6)
ambulation status;
(7)
administrative and social information; and
(8) needed continued care and
instructions.
