HAR §11-89-18. Records and reports

(a) Individual records shall be maintained for each resident. Upon admission or readmission, the facility shall maintain: (1) Records which identify the resident's name, social security number, marital status, date of birth, sex, next of kin or guardian, and religious preference, if any. A record of the address and telephone number of the referral agency or source by which the resident was admitted, the attending physician, dentist, and other medical or social service professionals who are currently involved in providing services to the resident, as well as a record of the agency responsible for financial payment, and the medical insurance plan; (2) A report of a medical examination current to within nine months and current diagnosis, physician's orders for medication, diet, special appliances and equipment, treatment, evaluations or direct service to be provided by a 89-24 1516 §11-89-18 physical therapist, occupational therapist, or speech pathologist and a report of an examination for tuberculosis performed within the year prior to admission, height and weight and medical history; (3) Copies of the resident's individual plan; and (4) An inventory of money and valuables. This inventory shall be kept current. (b) During residence, records shall be maintained by the caregiver and shall include the following information: (1) Copies of physician's initial, annual and other periodic examinations, evaluations, medical progress notes, relevant laboratory reports, and a report of re-examination of tuberculosis; (2) Observations of the resident's response to medication, treatments, diet, provision of care, response to activities programs, indications of illness or injury, unusual skin problems, changes in behavior patterns, noting the date, time and actions taken, if any, which shall be recorded monthly or more often as appropriate but immediately when an incident occurs; (3) Entries by the caregiver describing treatments and services rendered; (4) Medications made available; (5) Physician's signed orders for diet, medications, special appliances, adaptive equipment, and treatments; (6) All recordings of temperature, pulse, respiration as ordered by a physician or as may appear to be needed. Physicians shall be promptly advised of any changes in physical or mental status; (7) Recording of resident's weight at least once a month, and more often when requested by a physician; (8) Notation of visits and consultations made to residents by other authorized personnel; and (9) Correspondence pertaining to the resident's physical and mental status. 89-25 1516