63M-2.063. Interdisciplinary Health Record

This section of the IHCR shall include the forms listed below and organized in this order: (1) Practitioner’s Orders; (2) Chronological Progress Notes includes but not limited to: all health encounters (sick call, episodic and emergency care, report of health care by non-health care staff, chronological progress notes for nursing and practitioners as well as incidental notes in reverse chronological order); (3) Summary of Off-Site Care (HS 033); (4) Medication Administration Record(s) (MAR) (HS 019); (5) Prior Medical/Physical Assessments and Histories; (6) Prior Facility Entry Physical Health Screenings; (7) Laboratory Tests; (8) Radiological Tests; (9) Mental Health/Behavioral Health Care; and, (10) Dental Care and consents for dental care.