| (a) The facility shall maintain for each resident admitted,
a separate record with all entries kept current, dated and signed
by the recorder. The record shall be accurately written, promptly
completed, properly stored and filed, and accessible. At a minimum,
the record shall include:
(1) identification data. The facility shall secure
at the time of admission appropriate identifying information, including
full name; sex; date of birth; usual occupation; social security number;
family/friend name, address, and telephone number; and physician names
and telephone numbers including emergency numbers;
(2) medical history and physical exam reports, if available;
(3) any physician orders and progress notes, if available;
(4) any documentation of the resident's change in health
condition requiring emergency procedures, and health services provided
by facility personnel;
(5) other documents or reports related to the care
of the resident as required by facility policy;
(6) if appropriate, documentation of nursing services
provided and nursing staff observation as required by facility policy;
and
(7) a list of medications the resident is taking.
(b) The facility director shall be responsible for
the organization and management of the resident file.
(c) The facility will protect the resident file against
loss, damage, destruction, and unauthorized use by:
(1) safeguarding the confidentiality of the resident
file and allowing access or release only as specifically allowed by
federal or state laws;
(2) maintaining files in an organized manner and filing
them using an organized system;
(3) recording entries in ink, computer, or typewritten
format and keeping original reports and records; and
(4) storing files in a lockable area during non-use
and after resident's discharge.
(d) Resident files must be retained for at least five
years after services end. In the case of a minor, the resident file
must be retained for at least three years after the minor reaches
majority under state law.
(e) The facility may not destroy resident files that
relate to any matter that is involved in litigation if the facility
knows the litigation has not been finally resolved.
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