Cal. Code Regs. Tit. 22, § 72547 - Content of Health Records
(a) A facility shall maintain for each
patient a health record which shall include:
(1) Admission record.
(2) Current report of physical examination,
and evidence of tuberculosis screening.
(3) Current diagnoses.
(4) The orders of a licensed health care
practitioner acting within the scope of his or her professional licensure,
including drugs, treatment and diet orders, progress notes, signed and dated on
each visit. The orders of a licensed health care practitioner acting within the
scope of his or her professional licensure shall be correctly
recapitulated.
(5) Nurses' notes
which shall be signed and dated. Nurses' notes shall include:
(A) Records made by nurse assistants, after
proper instruction, which shall include:
1.
Care and treatment of the patient.
2. Narrative notes of observation of how the
patient looks, feels, eats, drinks, reacts, interacts and the degree of
dependency and motivation toward improved health.
3. Notification to the licensed nurse of
changes in the patient's condition.
(B) Meaningful and informative nurses'
progress notes written by licensed nurses as often as the patient's condition
warrants. However, weekly nurses' progress notes shall be written by licensed
nurses on each patient and shall be specific to the patient's needs, the
patient care plan and the patient's response to care and treatments.
(C) Name, dosage and time of administration
of drugs, the route of administration or site of injection, if other than oral.
If the scheduled time is indicated on the record, the initial of the person
administering the dose shall be recorded, provided that the drug is given
within one hour of the scheduled time. If the scheduled time is not recorded,
the person administering the dose shall record both initials and the time of
administration. Medication and treatment records shall contain the name and
professional title of staff signing by initials.
(D) Justification for the results of the
administration of all PRN medications and the withholding of scheduled
medications.
(E) Record of type of
restraint and time of application and removal. The time of application and
removal shall not be required for postural supports used for the support and
protection of the patient.
(F)
Medications and treatments administered and recorded as prescribed.
(G) Documentation of oxygen
administration.
(6)
Temperature, pulse, respiration and blood pressure notations when
indicated.
(7) Laboratory reports
of all tests prescribed and completed.
(8) Reports of all X-rays prescribed and
completed.
(9) Progress notes
written and dated by the activity leader at least quarterly.
(10) Discharge planning notes when
applicable.
(11) Observation and
information pertinent to the patient's diet recorded in the patient's health
record by the dietitian, nurse or food service supervisor.
(12) Records of each treatment given by the
therapist, weekly progress notes and a record of reports to the licensed health
care practitioner acting within the scope of his or her professional licensure
after the first two weeks of therapy and at least every 30 days thereafter.
Progress notes written by the social service worker if the patient is receiving
social services.
(13) Consent forms
for prescribed treatment and medication not included in the admission consent
for care.
(14) Condition and
diagnoses of the patient at time of discharge or final disposition.
(15) A copy of the transfer form when the
patient is transferred to another health facility.
(16) An inventory of all patients' personal
effects and valuables as defined in Section
72545(a) (12)
made upon admission and discharge. The inventory list shall be signed by a
representative of the facility and the patient or his authorized representative
with one copy to be retained by each.
(17) The name, complete address and telephone
number where the patient was transferred upon discharge from the
facility.
Notes
Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.