R432-150-25. Medical Records

  (1) The facility must implement a medical records system to ensure complete and accurate retrieval and compilation of information.

  (2) The administrator must designate an employee to be responsible and accountable for the processing of medical records.

  (a) The medical records department must be under the direction of a registered record administrator, RRA, or an accredited record technician, ART.

  (b) If an RRA or ART is not employed at least part time, the facility must consult with an RRA or ART according to the needs of the facility, but not less than semi-annually.

  (3) The resident medical record and its contents must be retained, stored and safeguarded from loss, defacement, tampering, and damage from fires and floods.

  (a) Medical records must be protected against access by unauthorized individuals.

  (b) Medical records must be retained for at least seven years. Medical records of minors must be kept until the age of eighteen plus four years, but in no case less than seven years.

  (4) The facility must maintain an individual medical record for each resident. The medical record must contain written documentation of the following:

  (a) records made by staff regarding daily care of the resident;

  (b) informative progress notes by staff to record changes in the resident's condition and response to care and treatment in accordance with the care plan;

  (c) a pre-admission screening;

  (d) an admission record with demographic information and resident identification data;

  (e) a history and physical examination up-to-date at the time of the resident's admission;

  (f) written and signed informed consent;

  (g) orders by clinical staff members;

  (h) a record of assessments, including the comprehensive resident assessment, care plan, and services provided;

  (i) nursing notes;

  (j) monthly nursing summaries;

  (k) quarterly resident assessments;

  (l) a record of medications and treatments administered;

  (m) laboratory and radiology reports;

  (n) a discharge summary for the resident to include a note of condition, instructions given, and referral as appropriate;

  (o) a service agreement if respite services are provided;

  (p) physician treatment orders; and

  (q) information pertaining to incidents, accidents and injuries.

  (r) If a resident has an advanced directive, the resident's record must contain a copy of the advanced directive.

  (5) All entries into the medical record must be authenticated including date, name or identifier initials, and title of the person making the entries.

  (6) Resident respite records must be maintained within the facility.