WAC 388-107-0560. Resident records — Clinical records

(1) The enhanced services facility must: (a) Maintain clinical records on each resident in accordance with accepted professional standards and practices that are: (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized; (b) Safeguard clinical record information against alteration, loss, destruction, and unauthorized use; and (c) Keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is required by: (i) Transfer to another health care institution; (ii) Law; or (iii) The resident. (2) The enhanced services facility must ensure the clinical record of each resident includes a minimum of the following: (a) Resident identification and sociological data, including, but not limited to: (i) Name; (ii) Room number; (iii) Telephone number, if available; (iv) Email address, if available; (v) Name and address of the individual or individuals the resident designates as significant; and (vi) If a resident has a representative, the following representative information: (A) Name; (B) Relationship to the resident; (C) Phone number; (D) Email address, if available; and (E) Mailing address, if available. (b) Medical information; (c) Physician's orders; (d) Assessments; (e) Person-centered service plans; (f) Services provided; (g) Progress notes; (h) Medications administered; (i) Consents, authorizations, releases; (j) Allergic responses; (k) Laboratory, X-ray, and other findings; (l) The residency agreement for residents with medicaid as a payor; and (m) Other records as appropriate. (3) The enhanced services facility must maintain resident records and preserve their confidentiality in accordance with applicable state and federal statutes and rules, including chapter 70.02 RCW.