South Carolina Code of Regulations › Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL › Subchapter 61-17 - STANDARDS FOR LICENSING NURSING HOMES › Sec2 61-17.800 - RESIDENT RECORDS › Section 61-17.800.801 - Content (II)

Current through Register Vol. 48, No. 6, June 28, 2024
A. All entries
				in the resident record shall be legible and complete, and shall be separately
				authenticated and dated promptly by the individual, identified by name and
				discipline, who is responsible for ordering, providing or evaluating the
				service or care furnished. Authentication may include written signatures or
				computerized or electronic entries. If an entry is signed on a date other than
				the date it was made, the date of the signature shall also be entered. Although
				use of initials in lieu of signatures is not encouraged, initials will be
				accepted provided such initials can be readily identified within the resident
				record.
B. Contents of the
				resident record may be stored in separate files, in separate areas within the
				facility, and the record shall include the following information:
1. Medical history and physical
				examination;
2. Consent form for
				treatment signed by the resident or his or her legal representative;
3. Care and services agreement;
4. Healthcare directives and special
				information, for example, advance directive information, do-not-resuscitate
				(DNR) orders, allergies;
5.
				Accidents and/or Incidents involving the resident; (I)
6. Medical treatment;
7. Orders, including telephone and standing
				orders, for all medication, care, services, therapy, procedures, and diet from
				physicians or other legally authorized healthcare providers, which shall be
				completed prior to, or at the time of admission, and subsequently, as
				warranted;
8. Individual Care Plan;
				(I)
9. Provisions for routine and
				emergency medical care, to include the name and telephone number of the
				resident's physician;
10.
				Assessments and progress notes, for example, dietary, activity,
				therapy;
11. Record of
				administration of each dose of medication; (I)
12. Record of the use of restraints, if
				applicable, including time, type, reason and authority for applying; (I)
13. Treatment, procedure, wound
				care report (dictated or written into the record after treatment, procedure, or
				wound care) to include at least: (I)
a.
				Description of findings;
b.
				Techniques utilized to perform treatments and procedures;
c. Specimens removed, if
				applicable;
d. Name of
				provider;
14. Progress
				notes generated by physicians and healthcare professionals;
15. Notes of observation, including
				temperature, pulse, respiration, blood pressure and weight when indicated by
				physician's orders or by a change in the resident's condition; (I)
16. Special procedures and preventive
				measures performed, for example, isolation for symptoms, diagnosis, and/or
				treatment of infectious conditions including but not limited to tuberculosis,
				influenza, pneumonia, therapies;
17. Reports of all laboratory, radiological,
				and diagnostic procedures along with tests performed and the results
				appropriately authenticated; (I)
18. Consultations by physicians or other
				healthcare professionals;
19.
				Photograph of resident, if the resident or his or her responsible party
				approves;
20. Date and hour of
				discharge or transfer, as applicable;
21. Discharge and/or transfer summary,
				including care and condition at discharge or transfer, date and time of
				discharge or transfer, instructions for self-care, instructions for obtaining
				post-treatment or procedure emergency care, and signature of physician
				authorizing discharge or transfer;
22. Date and circumstances of death, as
				applicable.