South Carolina Code of Regulations › Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL › Subchapter 61-103 - Residential Treatment Facilities for Children and Adolescents › Sec2 61-103.700 - RESIDENT RECORDS › Section 61-103.700.701 - Content (II)

Current through Register Vol. 48, No. 6, June 28, 2024
A. The facility
				shall initiate and maintain onsite an organized record for each resident. The
				record shall contain sufficient documented information to identify the resident
				and the agency and/or person responsible for each resident; support the
				diagnosis, secure the appropriate care and/or services as needed; justify the
				care and/or services provided to include the course of action taken and
				results; the symptoms or other indications of sickness or injury; changes in
				physical, mental, and/or behavioral condition; the response or reaction to
				care, medication, and diet provided; and promote continuity of care among
				providers, consistent with acceptable standards of practice. All entries shall
				be written legibly in ink, typed or electronic media, and signed and
				dated.
B. Specific entries and/or
				documentation shall include at a minimum:
1.
				Personal data sheet to include the following information, when obtainable:
				resident name; address including county; occupation; date of birth; sex;
				marital status; race; religion; county of birth; father's name; mother's maiden
				name; husband's or wife's name; health insurance number; provisional diagnosis;
				case number; days of care; Social Security number; name of the person providing
				information; name, address, and telephone number of person(s) to be notified in
				the event of an emergency; name and address of referral source; name of
				attending physician; and date and hour of admission;
2. Consultations by physicians or other
				authorized healthcare providers;
3.
				Orders and recommendations for all medication, care, services, procedures, and
				diet from physicians or other authorized healthcare providers, which shall be
				completed prior to, or within forty-eight (48) hours after admission, and
				thereafter as warranted. Verbal orders received shall be documented and include
				the date and time of receipt of the order, description of the order, and
				identification of the individual receiving the order;
4. Medication Administration Record (MAR) or
				similar document for recording of medications, treatments, and other pertinent
				data and procedures followed if an error is made;
5. Special examinations, if any, for example,
				consultations, clinical laboratory, x-ray and other examinations;
6. Notes of observation. In instances that
				involve significant changes in a resident's medical and/or mental condition
				and/or the occurrence of a serious incident, notes of observation shall be
				documented at least daily until the condition is stabilized and/or the incident
				is resolved. In all other instances, notes of observation for residents shall
				be documented;
7. Progress notes
				from all treatment services;
8.
				Time, circumstances, final diagnosis and condition of discharge, transfer, or
				death. In case of death, cause and autopsy findings, if an autopsy is
				performed;
9. Provisions for
				routine and emergency medical care, to include the name and telephone number of
				the resident's physician, plan for payment, and plan for securing
				medications;
10. Special
				information, such as proof of legal guardianship status, allergies, power of
				attorney, or responsible party;
11.
				Photograph of resident. Resident photographs shall be at a minimum two and one
				half inches by three and one half inches (2.5" by 3.5") in size, dated no more
				than twelve (12) months old, unless significant changes in appearance have
				occurred necessitating a more recent photograph;
12. Psychological testing;
13. Childhood development history;
14. Immunization history;
15. Psychosocial assessment, care
				plan;
16. Preadmission
				identification of current legal status, such as proof of custody;
17. Educational testing and prior educational
				records, when available upon request;
18. Treatment plan;
19. Activities assessment, care plan;
				and
20. Comprehensive treatment
				plan formulated by interdisciplinary team.