South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-103 - Residential Treatment Facilities for Children and Adolescents
Section 61-103.G - Clinical Records and Reports

Universal Citation: SC Code Regs 61-103.G

Current through Register Vol. 48, No. 9, September 27, 2024

(1) Clinical Records and Reports: (II)

(a) Physician's Responsibility: It shall be the responsibility of each attending physician to complete and sign the clinical record within a stipulated time after the discharge of the resident consistent with good medical practice. The use of rubber stamp signature is acceptable under the following strict conditions:
(1) The physician whose signature the rubber stamp represents is the only one who has possession of the stamp and is the only one who uses it, and

(2) The physician places in the administrative offices of the residential treatment facility a signed statement to the effect that he is the only one who has the stamp and is the only one who will use it. However, it must be emphasized that use of rubber stamp signatures is not permissible on orders for drugs listed as "controlled substances" under "Rules and Regulations Pertaining to Controlled Substances," R61-4 of the South Carolina Code of Laws of 1976.

(b) Organization: The responsibility for supervision, filing and indexing of records shall be assigned to a responsible employee of the residential treatment facility who has had training in this field.

(c) Indexing: Clinical records shall be properly indexed and filed for ready access by members of the staff.

(d) Ownership: Records of residents are the property of the facility and must not be taken from the residential treatment facility property except by court order.

(e) Contents: Adequate and complete clinical records shall be written for all residents admitted to the facility. All notes shall be legibly written or typed and signed. Although use of initials in lieu of licensed nurses' signatures is not encouraged, initials will be accepted provided such initials can be readily identified within the medical record. A minimum clinical record shall include the following information:
(1) Admission Record: An admission record must be prepared for each resident and must contain the following information, when obtainable: name; address, including county; occupation; date of birth; sex; marital status; race; religion; county of birth; father's name; mother's maiden name; husband's or wife's name; health insurance number; provisional diagnosis; case number; days of care; social security number; the name of the person providing information; name, address and telephone number of person or persons to be notified in the event of emergency; name and address of referral source; name of attending physician; date and hour of admission;

(2) medical history and physical within 5 days prior or 96 hours after admission; provisional and working diagnosis;

(3) psychiatric/diagnostic evaluation 5 days prior or 96 hours after admission; provisional or working diagnosis;

(4) medical treatment;

(5) dietary assessment, care plan;

(6) progress notes from all treatment services;

(7) Medication Administration Record or similar document for recording of medications, treatments and other pertinent data. The staff member shall sign this record after each medication administered or treatment rendered;

(8) final diagnosis and discharge summary;

(9) date and hour of discharge;

(10) in case of death, cause and autopsy findings, if autopsy is performed;

(11) special examinations, if any, e.g., consultations, clinical laboratory, x-ray and other examinations;

(12) psychological testing: complete battery within the past twelve months with repeated selected tests on admission or a complete battery of tests within thirty days when tests have not been done prior to admission.

(13) childhood development history;

(14) immunization history;

(15) psychosocial assessment, care plan;

(16) preadmission identification of current legal status, e.g., proof of custody;

(17) educational testing and prior educational records;

(18) treatment plan;

(19) activities assessment, care plan;

(20) comprehensive treatment plan formulated by interdisciplinary team.

(2) Orders for Medication and Treatment: All clinical records shall contain the orders for medication and treatment written in ink and signed and dated by the prescriber or his designee. All orders, including verbal orders, shall be properly recorded in the clinical record and dated and signed by the prescriber or designee within 48 hours. (I)

(3) Storage and Microfilming: (II)

(a) Provisions shall be made by the facility for the storage of clinical records in an environment which will prevent unauthorized access and deterioration. The records shall be treated as confidential and shall not be disposed of under 10 years. Records may be destroyed after 10 years provided that:
(1) Records of minors must be retained until after the expiration of the period of election following achievement of majority as prescribed by statute.

(2) The facility retains an index, register, or summary cards providing such basic information as dates of admission and discharge, name of responsible physician, and record of diagnoses and operations for all records so destroyed.

(b) Facilities that microfilm before 10 years have expired must film the entire record.

(c) In the event of change of ownership, all clinical records shall be transferred to the new owners.

(d) Prior to the closing of a facility for any reason, the facility shall arrange for preservation of records to insure compliance with these regulations. The facility shall notify the Department, in writing, describing these arrangements.

(4) Information to be Provided to Other Health Care Providers: In order to contribute to the continuity of quality of care, procedures must be established and implemented to provide discharge summaries and/or other appropriate information to health care providers to whom residents are discharged, transferred or referred.

Disclaimer: These regulations may not be the most recent version. South Carolina 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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