Cal. Code Regs. Tit. 22, § 76559 - Admission Records
(a) A
facility shall complete for each client an admission record which shall include
the following:
(1) Name and Social Security
number or other identifying number.
(2) Current address.
(3) Age and date of birth.
(4) Sex.
(5) Marital status.
(6) Date of admission.
(7) Date of discharge.
(8) Name, address and telephone number of
next of kin, guardian, authorized representative and agency responsible for
client.
(9) Name, address and
telephone number of attending physician and of the podiatrist, dentist or
clinical psychologist, if such practitioner is primarily responsible for the
treatment of the client.
(10) Name,
address and telephone number of the designated alternate physician.
(11) Admission diagnosis, known allergies and
final diagnosis.
(12) Medicare and
Medi-Cal numbers when appropriate.
(13) Reason for admission or referral
problem.
(14) Type and legal status
of admission.
(15) Legal competency
status.
(16) Language spoken or
understood.
(17) Information
relevant to religious affiliation.
(18) Citizenship.
(19) Parents' marital status.
(20) Medication history, as required by
Section 76589(a)(5).
Notes
Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Sections 1276, 1315, 1316 and 1316.5, Health and Safety Code.
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