Washington Administrative Code › Title 246 - Health, Department of › FACILITY STANDARDS AND LICENSING › Chapter 246-337 - Residential treatment facility › Section 246-337-095 - Resident health care records

Current through Register Vol. 24-14, July 15, 2024
The licensee must ensure the RTF meets the following
				  requirements:
(1) Develop and
				implement procedures for maintaining current health care records as required by
				chapter 70.02 RCW and other applicable laws.
(2) Health care records may be integrated
				into a resident's individual service plan so long as the requirements of this
				section are met.
(3) Make health
				care records accessible for review by appropriate direct care staff, the
				resident, the parent or guardian, and the department in accordance with
				applicable law.
(4) Document health
				care information in a standardized manner.
(5) Record health care information by the
				health care provider or direct care staff with resident contact to include
				typed or legible handwriting in ink, verified by signature or unique
				identifier, title, date and time.
(6) Maintain the confidentiality and security
				of health care records in accordance with applicable law.
(7) Maintain health care records in
				chronological order in their entirety or chronologically by sections.
(8) Keep health care records current with all
				documents filed according to the licensee's written timeline policy.
(9) Include the following, at a minimum, in
				each health care record:
(a) Resident's name,
				date of birth, sex, marital status, date of admission, voluntary or other
				commitment, name of health care prescriber, diagnosis, date of discharge,
				previous address and phone number, if any;
(b) Resident's receipt of notification of
				resident's rights;
(c) Resident's
				consent for health care provided by the RTF, unless the resident is admitted
				under an involuntary court order;
(d) A copy of any authorizations, advance
				directives, powers of attorney, letters of guardianship, or other similar
				documentation;
(e) Original
				reports, where available or, if not available, durable, legible copies of
				original reports on all tests, procedures, and examinations performed on the
				resident;
(f) Individual service
				plan according to WAC 246-337-100 or
				246-337-103, as
				applicable;
(g) Individuals whom
				the resident consents for the RTF to freely communicate with regarding the
				health care of the resident including the individual's name, relationship to
				the resident, and address;
(h)
				Dated and signed notes describing all health care provided for each contact
				with the resident pertinent to the resident's individual service plan
				including:
(i) Physical and psychosocial
				history;
(ii) Health
				screening;
(iii) Health care
				service and treatment provided, including resident's response to treatment and
				any adverse reactions and resolution of health care issues and when
				applicable;
(iv) Medication
				administration, and medical staff notification of medication administration
				errors, adverse effects, or side effects;
(v) Use of restraint or seclusion consistent
				with WAC 246-337-110;
(vi) Staff actions or response to health care
				needs;
(vii) Instructions or
				teaching provided to the resident in connection with his or her health care;
				and
(viii) Discharge summary,
				including:
(A) Summary of the resident's
				physical and mental history, as applicable;
(B) Condition upon discharge;
(C) List of current medications;
(D) Recommendations for services, follow-up
				or continuing care; and
(E) Date
				and time of discharge.