Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 390 - MEDICALLY COMPLEX FOR THE DEVELOPMENTALLY DISABLED FACILITIES CODE › Subpart H - RESIDENT AND FACILITY RECORDS › Section 390.1660 - Other Resident Record Requirements

Current through Register Vol. 48, No. 28, July 12, 2024
This Section contains references to rules located in other
				  Subparts that pertain to the content and maintenance of medical records.
a) The resident's record shall include facts
				involved if the resident's discharge occurs despite medical advice to the
				contrary, as required by Section
				390.630(d)
				of this Part.
b) The resident's
				record shall include information regarding the physician's notification and
				response regarding any serious accident or injury, or significant change in
				condition, as required by Section
				390.1030(j)
				of this Part.
c) The resident's
				record shall contain the physician's permission, with contraindications noted,
				for participation in the activity program, as required by Section
				390.1100(d)
				of this Part.
d) The records of
				residents participating in work activity or prevocational training programs
				shall document the appropriateness of the program for the resident and the
				resident's response to the program, as described in Section
				390.1120(b)
				of this Part.
e) The resident's
				record shall identify the reasons for any order and use of safety devices or
				restraints, as required by Section
				390.1310(e)
				of this Part.
f) The resident's
				record shall contain any orders specifying the use of mechanical or chemical
				restraints in a behavior emergency, as specified in Section
				390.1330(c)
				of this Part.
g) Telephone orders
				shall be transcribed into the resident's medical record or a telephone order
				form and signed by the nurse taking the order, as described in Section
				390.1420(a)
				of this Part.
h) Documentation of
				the review of medication orders shall be entered in the resident's medical
				record as described in Section
				390.1420(b)
				of this Part.
i) The resident's
				medical record shall include notations indicating any release of medications to
				the resident or person responsible for the resident's care, as described in
				Section
				390.1420(e)
				of this Part.
j) Instances of
				inability to implement a physician's medication order shall be noted in the
				resident's medical record, as described in Section
				390.1430(d)
				of this Part.
k) Medication errors
				and drug reactions shall be noted in the resident's medical record as described
				in Section
				390.1430(e)
				of this Part.
l) The resident's
				record shall include the physician's diet order and observations of the
				resident's response to the diet, as described in Section
				390.1840(a) and
				(c) of this Part.
m) The resident's record shall contain any
				physician determinations that limit the resident's access to the resident's
				personal property, as described in Section
				390.3210(b)
				of this Part.
n) The facility shall
				comply with Section
				390.3210(g)
				of this Part, which requires that any medical inadvisability regarding married
				residents residing in the same room be documented in the resident's
				record.
o) The facility shall
				maintain a record of approval granted for children of both sexes over the age
				of six who occupy the same room, as described in Sections
				390.660(c),
				390.2660(b)(5),
				and
				390.2960(a)(5)
				 of this Part.
p) The facility shall permit each resident,
				resident's parent, guardian or representative to inspect and copy the
				resident's medical records as provided by Section
				390.3220(g)
				of this Part.
q) Any resident
				transfer or discharge mandated by the physical safety of other residents shall
				be documented in the resident's medical record as required by Sections
				390.3300(d) and
				(g) of this Part.
r) Summaries of discussions and explanations
				of any planned involuntary transfers or discharged shall be included in the
				medical record of the resident that is to be involuntarily transferred or
				discharged, as described in Section
				390.3300(j)
				of this Part.