Content of Medical Records

Section 340 Section 340.1810  Content of Medical Records a)         No later than the time of admission, the facility shall enter the following information, as applicable, onto the identification or admission sheet for each resident. 1)         Name, sex, date of birth and Social Security Number; 2)         Marital Status, and the name of spouse; 3)         Date of admission to the facility; 4)         Date of current admission to the facility; 5)         State or country of birth; 6)         Home address; 7)         Religious affiliation; 8)         Name, address and telephone number of any referring agency, State hospital, zone center or hospital from which the resident has been transferred; 9)         Name and telephone number of the resident's personal physician; 10)         Name and telephone number of the resident's representative or guardian, if any; 11)         Name and telephone number of the resident's next of kin or responsible relative; 12)         Language understood or spoken; 13)         Race and origin; 14)         Most recent occupation; 15)         Whether the resident or the resident's spouse is a veteran; 16)         Father's name and mother's name; 17)         Name, address and telephone number of the resident's dentist; and 18)         The diagnosis applicable at the time of admission. b)         In addition to the information that is specified above, each resident's medical record shall contain the following: 1)         Medical history and physical examination form that includes conditions for which medications have been prescribed, physician findings, all known diagnoses and restoration potential.  This shall describe those known conditions that the medical and resident care staff should be apprised of regarding the resident.  Examples of diagnoses and conditions that are to be included are allergies, epilepsy, diabetes and asthma. 2)         A physician's order sheet that includes orders for all medications, treatments, therapy and rehabilitation services, diet, activities and special procedures or orders required for the safety and well-being of the resident. 3)         Nurse's notes that describe the nursing care provided, observations and assessment of symptoms, reactions to treatments and medications, progression toward or regression from each resident's established goals, and changes in the resident's physical or emotional condition. 4)         An ongoing record of notations describing significant observations or developments regarding each resident's condition and response to treatments and programs. A)        Physicians and other consultants who provide direct care or treatment to residents shall make notations at the time of each visit with a resident. B)        Significant observations or developments regarding resident responses to activity programs, social services, dietary services and work programs shall be recorded as they are noted.  If no significant observations or developments are noted for three months, an entry shall be made in the record of that fact. C)        Significant observations or developments regarding resident responses to nursing and personal care shall be recorded as they are noted.  If no significant observations or developments are noted for a month, an entry shall be made in the record of that fact. D)        Significant behavior incidents, reactions to any family visits and contacts, attendance at programs. 5)         Any laboratory and x-ray reports ordered by the resident's physician. 6)         Documentation of visits to the resident by a physician and to the physician's office by the resident.  The physician shall record, or dictate and sign, the results of such visits, such as changes in medication, observations, and recommendations made by the physician during the visits, in the record. 7)         All psychological testing and multidisciplinary evaluations regarding each resident. 8)         Any correspondence pertaining to the resident's program. 9)         Appropriate authorizations and consents. 10)         Upon admission from a hospital or State facility, a hospital summary sheet or transfer form that includes the hospital diagnosis and treatment, and a discharge summary.  This transfer information, which may be included in the transfer agreement, shall be signed by the physician who attended the resident while in the hospital.