4658.0450 Clinical Record Contents


Published: 2015

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4658.0450 CLINICAL RECORD CONTENTS.


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Subpart 1.

In general.

Each resident's clinical record, including nursing notes, must include:

§
A.

the condition of the resident at the time of admission;


§
B.

temperature, pulse, respiration, and blood pressure, according to part 4658.0520, subpart 2, item I;


§
C.

the resident's height and weight, according to part 4658.0520, subpart 2, item J;


§
D.

the resident's general condition, actions, and attitudes;


§
E.

observations, assessments, and interventions provided by all disciplines responsible for care of the resident, with the exception of confidential communications with religious personnel;


§
F.

significant observations on, for example, behavior, orientation, adjustment to the nursing home, judgment, or moods;


§
G.

date, time, quantity of dosage, and method of administration of all medications, and the signature of the nurse or authorized persons who administered the medication;


§
H.

a report of a tuberculin test within the three months prior to admission, as described in part 4658.0810;


§
I.

reports of laboratory examinations;


§
J.

dates and times of all treatments and dressings;


§
K.

dates and times of visits by all licensed health care practitioners;


§
L.

visits to clinics or hospitals;


§
M.

any orders or instructions relative to the comprehensive plan of care;


§
N.

any change in the resident's sleeping habits or appetite;


§
O.

pertinent factors regarding changes in the resident's general conditions; and


§
P.

results of the initial comprehensive resident assessment and all subsequent comprehensive assessments as described in part 4658.0400.



§
Subp. 2.

Physician and professional services.

The clinical record must contain the recording requirements of parts 4658.0710 to 4658.0725.


§
Subp. 3.

Nursing services.

The clinical record must contain the recording requirements of parts 4658.0515 to 4658.0530.


§
Subp. 4.

Dietary and food services.

The clinical record must contain the recording requirements of parts 4658.0600 and 4658.0625.


§
Subp. 5.

Resident personal funds account.

The clinical record must contain the recording requirements of part 4658.0255.


§
Subp. 6.

Activities.

The clinical record must contain the recording requirements of part 4658.0900.


§
Subp. 7.

Social services.

The clinical record must contain the recording requirements of parts 4658.1015 and 4658.1020.