Clinical and Related Records

(A) Each facility shall develop, through an interdisciplinary team, and adopt written policies and procedures to ensure complete and accurate clinical records are maintained for each resident and readily available as needed, including to the resident and his or her guardian and other providers as permitted by law or authorized by the resident or his or her guardian prior to submitting an application for a license. Each facility shall implement, review and revise, through an interdisciplinary team as needed, but not less than once a year, its written policies and procedures. A facility shall ensure all staff, including temporary staff and volunteers, are trained and determined to be competent as needed for their duties on such policies and procedures. (B) All records shall be complete, accurate, current, available on the premises of the facility . In addition to the clinical record for each resident, the following records shall be maintained: (1) Daily census; (2) Resident care policies; (3) Incident, fire, epidemic, emergency and other report forms; (4) Schedules of names, telephone numbers, dates and alternates for all emergency or "on call" personnel; (5) A Resident Roster approved by the Department; Orders for all medications, treatments, diets, rehabilitation services and medical procedures ordered for residents. Orders shall be dated, recorded and signed (telephone orders countersigned) by the resident’s primary care provider. If electronic signatures are permitted, the facility must ensure their system is designed to ensure integrity, authenticity and non-repudiation; (7) A record of narcotic and sedatives; A bound Day and Night Report Book with a stiff cover and numbered pages, or electronic record of reports with an audit trail; (9) Identification and summary sheets on all residents; (10) In a SNCFC, an Individual Service Plan (ISP) shall be developed for each resident. (C) All facilities shall maintain a separate, complete, accurate and current clinical record in the facility for each resident from the time of admission to the time of discharge. This record shall contain all medical, nursing and other related data. All entries shall be dated and signed. The clinical record shall include: (1) Identification and Summary Sheet including: resident’s name, bed and room number, social security number, age, sex, race, marital status, religion, home address, and date and time of admission; names, addresses and telephone numbers of primary care provider and alternates, of referring agency or institution, and of any other practitioner attending the resident (dentist, podiatrist); name, address and telephone number of emergency contact; admitting diagnosis, final diagnosis, and associated conditions on discharge; and placement. In a SNCFC, the data shall include the name, address and telephone number of the parent or guardian. (2) A Health Care Referral Form, Hospital Summary Discharge Sheets and other such information transferred from the agency or institution to the receiving facility. (3) Admission Data recorded and signed by the admitting nurse or responsible person including how admitted (ambulance, ambulation or other); referred by whom and accompanied by whom, date and time of admission; complete description of resident’s condition upon admission, including vital signs on all admissions and weight (if ambulatory); and date and time the resident’s primary care provider was notified of the admission. In a SNCFC, all residents including non-ambulatory residents shall have height and weight recorded upon admission. (4) Initial Medical Evaluation and medical care plan including medical history, physical examination, evaluation of mental and physical condition, diagnoses, orders and estimation of immediate and long-term health needs dated and signed by the resident’s primary care provider. (5) Primary Care Provider’s Progress Notes including significant changes in the resident’s condition, physical findings and recommendations recorded at each visit, and at the time of periodic reevaluation and revision of medical care plans. (6) Consultation Reports including consultations by all medical, psychiatric, dental or other professional personnel who are involved in resident care and services. Such records shall include date, signature and explanation of the visit, findings, treatments and recommendations. Medication and Treatment Record including date, time, dosage and method of administration of all medications; date and time of all treatments; special diets; rehabilitation services and special procedures for each resident, dated and signed by the nurse or individual who administers the medication or treatment. (8) A Record of all fires and all incidents involving residents. (9) A Nursing Care Plan for each resident. (10) Nurses Notes containing accurate reports of all factors pertaining to the resident’s needs or special problems and the overall nursing care provided. (11) Initial Plans and written evidence of periodic review and revision of dietary, social service, rehabilitation services, activity, and other resident care plans. (12) Laboratory and X-ray Reports. (13) A list of each resident’s clothing, personal effects, valuables, funds or other property. (14) Discharge or Transfer Data including a dated, signed primary care provider’s order for discharge; the reason for discharge and a summary of medical information, including physical and mental condition at time of discharge; a complete and accurate health care referral form; date and time of discharge; address of home, agency or institution to which discharged; accompanied by whom; and notation as to arrangements for continued care or follow-up. Utilization Review Plan, Minutes, Reports and Special Studies as described in 105 CMR 150.014. (D) All clinical records of residents including those receiving outpatient rehabilitation services shall be completed within two weeks of discharge and filed and retained for at least five years. Provisions shall be made for safe keeping for at least five years of all clinical records in the event the facility discontinues operation, and the Department shall be notified as to the location of the records and the person responsible for their maintenance. (E) All information contained in clinical records shall be treated as confidential and shall be disclosed only to authorized persons.