Current through Register Vol. 48, No. 9, September 27, 2024
A. The facility
shall initiate and maintain on site an organized record for each resident. The
record shall contain sufficient documented information to identify the resident
and the agency and/or person responsible for each resident; support the
diagnosis, secure the appropriate care/services (as needed); justify the
care/services provided to include the course-of-action taken and results; the
symptoms or other indications of sickness or injury; changes in physical/mental
condition; the response/reaction to care, medication, and diet provided; and
promote continuity of care among providers, consistent with acceptable
standards of practice. All entries shall be written legibly in ink, typed or
electronic media, and signed, and dated.
B. Specific entries/documentation shall
include at a minimum:
1. Consultations by
physicians or other authorized healthcare providers;
2. Orders and recommendations for all
medication, care, services, procedures, and diet from physicians or other
authorized healthcare providers, which shall be completed prior to, or at the
time of admission, and subsequently, as warranted. Verbal orders received shall
be documented and include the date/time of receipt of the order, description of
the order, and identification of the individual receiving the order;
3. Care/services provided, e.g., hospice,
home health;
4. Medications
administered and procedures followed if an error is made;
5. Special procedures and preventive measures
performed;
6. Notes of observation.
In instances that involve significant changes in a resident's medical condition
and/or the occurrence of a serious incident, notes of observation shall be
documented at least daily until the condition is stabilized and/or the incident
is resolved. In all other instances, notes of observation for residents shall
be documented at least monthly;
7.
Time, circumstances, and condition of discharge, transfer, or death;
8. Provisions for routine and emergency
medical care, to include the name and telephone number of the resident's
physician, plan for payment, and plan for securing medications;
9. Special information, e.g.,
do-not-resuscitate orders, allergies, power of attorney, responsible party,
etc.
10. Photograph of resident.
Resident photographs shall be at a minimum two and one half inches by three and
one half inches (2 1/2 by 3 1/2 inches) in size, dated and no more than
twenty-four (24) months old unless significant changes in appearance have
occurred necessitating a more recent photograph.
