South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-13 - Standards for Licensing Habilitation Centers for Persons with Intellectual Disability or Persons with Related Conditions
Sec2 61-13.800 - CLIENT RECORDS
Section 61-13.800.801 - Content (II)
Universal Citation: SC Code Regs 61-13.800.801
Current through Register Vol. 48, No. 9, September 27, 2024
A. A facility shall maintain adequate and complete records for each client. All entries shall be legibly written in ink or typed, dated, and signed, including title. If an entry is signed on a date other than the date it was made, the date of the signature shall also be entered. Although the use of initials in lieu of licensed nurses' signatures is not encouraged, initials shall be acceptable provided such initials can be readily identified by signature on each sheet on which the initials are used, or by signature on a master list which is maintained in the record at all times.
B. A minimum client record shall include the following:
1. Identification data:
a. Name, county, date of birth, sex, marital
status, religion, county of birth, father's name, mother's maiden name,
husband's or wife's name (if applicable), health insurance number, social
security number, diagnosis, case number dates of care, name of the person
providing information, and contact information for person(s) to be notified in
case of emergency.
b. Admission
agreement specifying available services and costs, and documentation of the
explanation of the client bill of rights and grievance procedures.
c. Name and telephone number of attending
physician.
d. Date and time of
admission.
2. Consent
form for treatment signed by the client or his or her legal
representative.
3. Record of
physical examination:
a. Physical
examination, to include but not be limited to, diagnosis and identification of
special conditions or care required, completed within one (1) month prior to or
within forty-eight (48) hours after admission.
b. Physician's orders for medication,
treatment, care, and diet, which must be reviewed and reordered at least once
every three (3) months by the physician.
4. Individual Program Plan. An individual
program plan shall be formulated or adopted within thirty (30) days of
admission. This plan shall be updated as necessary, but at least annually, to
reflect the current problems and needs of each client.
5. Social services. A social history,
psychosocial assessment, and progress notes shall be documented and updated as
necessary.
6. Activity services. An
activity assessment and progress notes shall be documented and updated as
necessary.
7. Dietary services. A
dietary assessment and progress notes shall be documented and updated as
necessary.
8. Nursing care record.
Record of all pertinent factors pertaining to the client's condition.
9. Assessments and progress notes regarding
psychological, behavioral, and therapeutic services shall be documented and
updated as necessary by the interdisciplinary team.
10. Record of all physicians' visits
subsequent to admission. Progress notes shall be entered after each visit to or
by the physician. Physician's orders for medications, treatment, care, and diet
shall be written in ink and signed by the prescriber or his or her
designee.
11. Discharge
summary.
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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