California Code of Regulations › Title 22 - Social Security › Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies › Chapter 3 - Skilled Nursing Facilities › Article 5 - Administration › Section 72547 - Content of Health Records

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A facility shall maintain for each
				  patient a health record which shall include:
(1) Admission record.
(2) Current report of physical examination,
				  and evidence of tuberculosis screening.
(3) Current diagnoses.
(4) The orders of a licensed health care
				  practitioner acting within the scope of his or her professional licensure,
				  including drugs, treatment and diet orders, progress notes, signed and dated on
				  each visit. The orders of a licensed health care practitioner acting within the
				  scope of his or her professional licensure shall be correctly
				  recapitulated.
(5) Nurses' notes
				  which shall be signed and dated. Nurses' notes shall include:
(A) Records made by nurse assistants, after
				  proper instruction, which shall include:
1.
				  Care and treatment of the patient.
2. Narrative notes of observation of how the
				  patient looks, feels, eats, drinks, reacts, interacts and the degree of
				  dependency and motivation toward improved health.
3. Notification to the licensed nurse of
				  changes in the patient's condition.
(B) Meaningful and informative nurses'
				  progress notes written by licensed nurses as often as the patient's condition
				  warrants. However, weekly nurses' progress notes shall be written by licensed
				  nurses on each patient and shall be specific to the patient's needs, the
				  patient care plan and the patient's response to care and treatments.
(C) Name, dosage and time of administration
				  of drugs, the route of administration or site of injection, if other than oral.
				  If the scheduled time is indicated on the record, the initial of the person
				  administering the dose shall be recorded, provided that the drug is given
				  within one hour of the scheduled time. If the scheduled time is not recorded,
				  the person administering the dose shall record both initials and the time of
				  administration. Medication and treatment records shall contain the name and
				  professional title of staff signing by initials.
(D) Justification for the results of the
				  administration of all PRN medications and the withholding of scheduled
				  medications.
(E) Record of type of
				  restraint and time of application and removal. The time of application and
				  removal shall not be required for postural supports used for the support and
				  protection of the patient.
(F)
				  Medications and treatments administered and recorded as prescribed.
(G) Documentation of oxygen
				  administration.
(6)
				  Temperature, pulse, respiration and blood pressure notations when
				  indicated.
(7) Laboratory reports
				  of all tests prescribed and completed.
(8) Reports of all X-rays prescribed and
				  completed.
(9) Progress notes
				  written and dated by the activity leader at least quarterly.
(10) Discharge planning notes when
				  applicable.
(11) Observation and
				  information pertinent to the patient's diet recorded in the patient's health
				  record by the dietitian, nurse or food service supervisor.
(12) Records of each treatment given by the
				  therapist, weekly progress notes and a record of reports to the licensed health
				  care practitioner acting within the scope of his or her professional licensure
				  after the first two weeks of therapy and at least every 30 days thereafter.
				  Progress notes written by the social service worker if the patient is receiving
				  social services.
(13) Consent forms
				  for prescribed treatment and medication not included in the admission consent
				  for care.
(14) Condition and
				  diagnoses of the patient at time of discharge or final disposition.
(15) A copy of the transfer form when the
				  patient is transferred to another health facility.
(16) An inventory of all patients' personal
				  effects and valuables as defined in Section
				  72545(a) (12)
				  made upon admission and discharge. The inventory list shall be signed by a
				  representative of the facility and the patient or his authorized representative
				  with one copy to be retained by each.
(17) The name, complete address and telephone
				  number where the patient was transferred upon discharge from the
				  facility.