MEDICAL INFORMATION FOR CLINICAL RECORD

A physician or physician designee must provide the following information for the clinical record: A. the report of the admission history and physical examination; B. the admitting diagnosis; C. a description of the general medical condition, including disabilities and limitations; D. a report of subsequent physical examinations; E. instructions relative to the resident's total program of care; F. written orders for all medications with stop dates, treatments, rehabilitations, and any medically prescribed special diets; G. progress notes; H. any advanced directives; and I. condition on discharge or transfer, or cause of death.