California Code of Regulations › Title 22 - Social Security › Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies › Chapter 4 - Intermediate Care Facilities › Article 4 - Administration › Section 73547 - 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 the following:
(1) Diagnoses (current).
(2) Drug and treatment orders.
(3) Diet orders.
(4) Progress notes written at the time of
				  visit by professional personnel in attendance to the patient.
(5) Nurses' notes which shall include:
(A) Narrative notes made by nurses' aides
				  when appropriate, and after such aides have been properly instructed. They
				  shall include:
1. Care and treatment done
				  with and for the patient.
2.
				  Patients' reactions to care and treatment.
3. Daily observation of how the patient
				  looks, feels, reacts, interacts, degree of dependency and motivation towards
				  improved health.
(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 personnel on each patient and shall be
				  specific to the psychological, emotional, social, spiritual, recreational needs
				  and related to the patient care plans.
Progress notes reflecting observations of the patient's
					 response to his environment, physical limitations, independent activities,
					 dependency status, behavioral changes, skin problems, dietary problems and
					 restorative measures to characterize the functional status of progression
					 and/or regression.
(C) Name,
				  dosage and time of administration of drugs, the route of administration if
				  other than oral and site of injection. 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 his initials and the time of administration.
(D) Justification for and the results of the
				  administration of all P.R.N. 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 soft tie restraints used for the support and
				  protection of the patient.
(F)
				  Medications and treatments administered and recorded as
				  prescribed.
(6) Current
				  history and physical examination or appropriate health evaluation.
(7) Temperature, pulse and respiration where
				  indicated.
(8) Laboratory reports
				  of all tests prescribed and completed.
(9) Reports of all X-rays prescribed and
				  taken.
(10) Condition and diagnosis
				  of patient at time of discharge and final disposition.
(11) Orders provided by a licensed healthcare
				  practitioner acting within the scope of his or her professional licensure,
				  including drug, treatment and diet orders signed on each visit. Orders provided
				  by the licensed healthcare practitioners acting within the scope of his or her
				  professional licensure recapitulated as appropriate.
(12) Observation and information pertinent to
				  the dietetic treatment recorded in the patient's health record by the dietitian
				  or nurse. Pertinent dietary records shall be included in patient's transfer
				  records to ensure continuity of nutritional care.
(13) Consent forms for prescribed treatment
				  and medication.
(14) An inventory
				  of all patients' personal effects and valuables 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.