Resident Records

(1) A TBI residential home provider shall develop and maintain an organized record for each resident and ensure that all entries shall be written legibly in ink, typed, or kept electronically, and signed, and dated. The provider shall keep a current record of active cases in the home. Historical records for each resident may be kept in the home or at the TBI residential home’s home office. (2) Personal record. A TBI residential home provider shall ensure that the resident’s personal record includes at a minimum the following: (a) Name, social security number, veteran status and number, marital status, age, sex, any health insurance provider and number, including Medicare and/or Medicaid number, and photograph of the resident; (b) Name, address and telephone number of next of kin, legal representative (if applicable), and any other person identified by the resident to contact on the resident’s behalf; (c) Name and address of the resident’s preferred physician, hospital, pharmacist and nursing home, and any other instructions from the resident to be followed in case of emergency; (d) Record of all monies and other valuables entrusted to the TBI residential home for safekeeping, with appropriate updates; (e) Date of admission, transfer, discharge and any new forwarding address; (f) A copy of the admission agreement that is signed and dated by the resident; (g) A copy of any advance directives, DNR Order, Durable Power of Attorney, or living will, when applicable, and made available upon request; and (h) A record that the resident has received a copy of the TBI residential home’s resident’s rights and procedures policy. (3) Medical record. A TBI residential home provider shall ensure that its staff develop and maintain a medical record for each resident who requires health care services at the TBI residential home regardless of whether such services are rendered by the TBI residential home or by resident self-direction, which shall include at a minimum: (a) Medical history; (b) Consultation by physicians or other authorized healthcare providers; (c) Orders and recommendations for all medication, medical and other care, services, procedures, and diet from physicians or other authorized healthcare providers, which shall be completed prior to, or at the time of admission, and subsequently, as warranted. Verbal orders received shall include the time of receipt of the order, description of the order, and identification of the individual receiving the order; TRAUMATIC BRAIN INJURY RESIDENTIAL HOMES CHAPTER 0720-38 (d) Medication Administration Record (MAR). A current, written medication administration record must be kept for each resident and must: 1. List the name of all medications administered by licensed staff, including over- the-counter medications and prescribed dietary supplements; 2. Identify the dosage, route, and the date and time each medication or supplement is to be given; 3. Identify any treatments and therapies given by licensed staff. The record must indicate the type of treatment or therapy and the time the procedure is to be performed; 4. Immediately be initialed by the licensed staff administering the medication, treatment or therapy as it is completed. Each medication administration record must contain a legible signature that identifies each set of initials; 5. Document changes and discontinued orders immediately, showing the date of the change or discontinued order; and 6. Document missed or refused medications, treatment or therapies. (e) Procedures followed in the event a medication error is made; (f) Special procedures and preventive measures performed; (g) Notes, including, but not limited to, observation notes, progress notes, and nursing notes; (h) Listing of current vaccinations; (i) Time and circumstances of discharge or transfer, including condition at discharge or transfer, or death; (j) Provisions of routine and emergency medical care, to include the name and telephone number of the resident’s physician, plan for payment, and plan for securing medications; and (k) Special information, e.g., allergies, etc. (4) Personal information shall be confidential and shall not be disclosed, except to the resident, the Department of Health and others with written authorization from the resident. Records shall be retained for three (3) years after the resident has been transferred or discharged.