Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 300 - SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE › Subpart I - RESIDENT AND FACILITY RECORDS › Section 300.1850 - 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
				300.620(f)
				of this Part.
b) The resident's
				record shall identify the reasons for any order and use of safety devices or
				restraints, as required by Sections
				300.680(c)
				and
				300.1040(d),
				respectively, of this Part.
c) 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
				300.1010(h)
				of this Part.
d) The resident's
				record shall contain the physician's permission, with contraindications noted,
				for participation in the activity program, as required by Section
				300.1410(d)
				of this Part.
e) The records of
				residents participating in work programs shall document the appropriateness of
				the program for the resident and the resident's response to the program, as
				described in Section
				300.1430(e)
				of this Part.
f) 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
				300.1620(a)(2)
				 of this Part.
g) Documentation of the review of medication
				order shall be entered in the resident's medical record as described in Section
				300.1620(b)
				of this Part.
h) 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
				300.1620(e)
				of this Part.
i) Instances of
				inability to implement a physician's medication order shall be noted in the
				resident's medical record, as described in Section
				300.1630(d)
				of this part.
j) Medication errors
				and drug reactions shall be noted in the resident's medical record as described
				in Section
				300.1630(e)
				of this Part.
k) The resident's
				record shall include the physician's diet order and observations of the
				resident's response to the diet, as describe in Section
				300.2040 of this
				Part.
l) 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
				300.3210(b)
				of this Part.
m) The facility shall
				comply with Section
				300.3210(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.
n) 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
				300.3220(g)
				of this Part.
o) 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
				300.3300(d) and
				(g) of this Part.
p) Summaries of discussions and explanations
				of any planned involuntary transfers or discharges shall be included in the
				medical record of the resident that is to be involuntarily transferred or
				discharged, as described in Section
				300.3300(j)
				of this Part.