Cal. Code Regs. Tit. 22, § 76927 - Content of Unit Client Record
(a) Each unit client record shall contain all
information necessary to develop and evaluate the individual service plan; to
document the client's progress and response to the plan; and, to protect the
legal rights of the client, the staff and the facility.
(b) The unit client record contents shall be
completed promptly at the conclusion of each required service or professional
visit or as specified elsewhere in these regulations.
(1) Verbal orders shall be signed by the
prescriber as specified in Section
76896(d)(2).
(2) Discharged unit client records shall be
completed within thirty days.
(c) All entries in the unit client record
shall be authenticated with the author's name, professional or job title, and
the date and time of the entry.
(d)
All entries and reports in the unit client record shall be permanent and
capable of being photocopied. Entries shall be legibly handwritten, typewritten
or electronically recorded.
(e) The
unit client record shall contain:
(1)
Admission record as required by Section
76926.
(2) Evidence of orientation to the facility
as required by Section
76865(h).
(3) Client assessments as follows:
(A) Initial identification of current level
of needs and functions as required by Section
76857(a)(11)(A).
(B) Medical, social and psychological
evaluations as required by Section
76915(a)(2).
(C) Review and update of initial assessments
as required by Section
76859(a)(1).
(D) Interdisciplinary team/staff assessment
as required by Section
76859(a)(2).
(E) Nursing evaluation/assessment of health
status as required by Section
76875(c).
(F) Assessment of bowel and bladder functions
as required by Section
76865(n)(1).
(G) Recreational interests as required by
Section 76859(c).
(H) Assessment of behavior, if applicable, as
required by Section
76869(c)(2).
(I) Nutritional status, if food is refused,
as required by Section
76882(b)(4).
(4) Physical examination as required by
Section 76878(b)(2)(A) and
(B).
(5) Dental examination as required by Section
76880(a).
(6) Integrated and coordinated individual
service plan developed by the interdisciplinary team/staff with input from
direct care staff. It shall contain elements as required by Section
76860(a)(1) through
(4).
(7) Recreational activity plan as required by
Section 76863(c).
(8) Health care plan as required by Section
76875(a)(2).
(9) Measures to prevent decubitus ulcers,
contractures, and deformities as required by Section
76865(1).
(10) Bowel and bladder training plan, if
applicable, as required by Section
76865(n)(2).
(11) Behavior management plan, if applicable,
as required by Section
76869(c)(3)(4).
(12) Discharge plan, when anticipated, as
required by Section
76860(a)(9).
(13) Review and update of the individual
service plan as required by Sections
76857(a)(11)(C),
76875(a)(3), and
76858(b)(3).
(14) Progress notes as required by Sections
76860(a)(8),
76865(n)(3),
76869(c)(5)(A) through
(D),
76867(d),
76874(e), and
76880(e).
(15) Notification of medication errors and
adverse reactions to the practitioner who ordered the drug as required by
Section 76876(h).
(17) Medication history as required by
Section 76894(a)(4).
(18) All diagnostic and therapeutic
prescriptions including diet and medications, as required by Sections
76874(e),
76864(b), and
76867(a).
(19) Medication and treatment administration
records as required by Sections
76876(b),
76874(b)(3) and
76874(b)(4).
(21) Vital signs and other flow sheet
records, if ordered.
(22) Restraint
records as required by Section
76868(a)(2) and
(3).
(23) Developmental, medical and psychiatric
diagnoses comprised of all admitting, concurrent and discharge conditions,
including allergies.
(24) Discharge
summary of treatment, including goals achieved and not achieved, and health
care treatment prepared by the responsible practitioner(s).
(25) Consent(s) to treatment.
(26) An inventory of all client's valuables
made upon admission and discharge. The inventory list shall be signed by a
representative of the facility and the client or the client's authorized
representative with one copy retained by each. The inventory list shall include
but not be limited to the following:
(A) Items
of jewelry.
(B) Items of
furniture.
(C) Radios, televisions
and other appliances.
(D)
Prosthetic devices.
(E) Other
valuable items so identified by the client, client's parents or authorized
representative.
Notes
Note: Authority cited: Sections 208.4 and 1267.7, Health and Safety Code. Reference: Section 1276, Health and Safety Code.
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