R432-151-21. Resident Records

  (1) These rules shall apply in addition to R432-150-25 and shall provide emphasis regarding resident records.

  (2) Contents of the resident record shall describe the resident's physical and mental health status at the time of admission, the services provided, the progress made, and the resident's physical and mental health status at the time of discharge.

  (3) The resident record shall contain the following:

  (a) Identifying data that is recorded on standardized forms:

  (i) the resident's name;

  (ii) home address;

  (iii) home telephone number;

  (iv) date of birth;

  (v) sex;

  (vi) race or ethnic origin;

  (vii) next of kin;

  (viii) education;

  (ix) marital status;

  (x) type and place of last employment;

  (xi) date of admission;

  (xii) legal status, including relevant legal documents;

  (xiii) date the information was gathered; and names and signatures of the staff members gathering the information.

  (b) Information for review and evaluation of treatment provided to the resident.

  (c) Documentation of resident and family involvement in the treatment program.

  (d) Prognosis.

  (e) Information on any unusual occurrences, such as treatment complications; accidents or injuries to or inflicted by the resident, procedures that place the resident at risk, AWOL.

  (f) Physical and mental diagnoses using a recognized diagnostic coding system.

  (g) Progress notes written by the physician, psychiatrist, nurse, and others involved in active treatment.

  (i) progress notes should contain an on-going assessment of the resident.

  (ii) Progress notes shall be written in the resident's record by each professional discipline at least monthly for the first three months and every other month thereafter at approximately 60 day intervals.

  (iii) Progress notes shall be summaries of notes written at more frequent intervals, as determined by the condition of the resident or by facility policy, including the following:

  (A) Documentation which supports implementation of the resident care plan and the resident's progress toward meeting these planned goals and objectives;

  (B) Documentation of all treatment and services rendered to the resident;

  (C) Chronological documentation of the resident's clinical course;

  (D) Descriptions of changes in the resident's condition;

  (E) Descriptions of resident response to treatment, the outcome of treatment, and the response of significant others to these changes.

  (iv) All entries involving subjective interpretation of the resident's progress should be supplemented with a description of the actual behavior observed.

  (v) Efforts should be made to secure written progress reports from outside sources for residents receiving services away from the facility.

  (h) Reports of laboratory, radiologic, or other diagnostic procedures, and reports of medical or surgical procedures when performed;

  (i) Correspondence and signed and dated notations of telephone calls concerning the resident's treatment.

  (j) A written plan for discharge including information about the following:

  (i) Resident's preferences and choices regarding location and plans for discharge;

  (ii) Family relationships and involvement with the resident;

  (iii) Physical and psychiatric needs;

  (iv) Realistic, basic financial needs;

  (v) Housing needs;

  (vi) Employment needs;

  (vii) Educational/vocational needs;

  (viii) Social needs;

  (ix) Accessibility to community resources;

  (x) Designated and documented responsibility of the resident or family for follow-up or aftercare.

  (k) A discharge summary signed by the physician and entered into the resident record within 60 calendar days from the date of discharge;

  (i) In the event a resident dies, the discharge statement shall include a summary of events leading to the death.

  (ii) Transfer to another facility for more than 72 hours shall cause the resident record to be closed with a discharge summary.

  (A) A new record shall be initiated at the time of readmission.

  (B) If the interval from discharge to readmission is less than 30 days, previous assessments may be reviewed and a copy brought forward from the prior record. The assessment must be identified either as an original or as a copy, and include updated information.

  (l) Reports of all assessments.

  (m) Consents for release of information, the actual date the information was released, and the signature of the staff member who released the information:

  (i) The facility may release pertinent information to personnel responsible for the individual's care without the resident's consent under the following circumstances:

  (A) In a life-threatening situation;

  (B) When an individual's condition or situation precludes obtaining written consent for release of information;

  (C) When obtaining written consent for release of information would cause an excessive delay in delivering treatment to the individual.

  (ii) When information has been released under the conditions listed in R432-151-21(3)(m), the transaction shall be entered into the resident's record, including at least the following:

  (A) The date the information was released;

  (B) The person to whom the information was released;

  (C) The reason the information was released;

  (D) The reason written consent for release of information could not be obtained;

  (E) The specific information released;

  (F) The name of the person who released the information.

  (iii) The resident shall be informed of the release of information as soon as possible.

  (n) Pertinent prior records available from outside sources.

  (4) The confidentiality of the records of substance abuse residents shall be maintained according to 42 CFR, Part 2, "Confidentiality of Alcohol and Drug Abuse Patient Records."