4658.0450 CLINICAL RECORD CONTENTS.


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Subpart 1.

In general.

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

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A.

the condition of the resident at the time of admission;


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B.

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


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C.

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


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D.

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


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E.

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


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F.

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


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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;


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H.

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


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I.

reports of laboratory examinations;


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J.

dates and times of all treatments and dressings;


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K.

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


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L.

visits to clinics or hospitals;


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M.

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


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N.

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


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O.

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


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P.

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



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Subp. 2.

Physician and professional services.

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


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Subp. 3.

Nursing services.

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


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Subp. 4.

Dietary and food services.

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


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Subp. 5.

Resident personal funds account.

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


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Subp. 6.

Activities.

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


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Subp. 7.

Social services.

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