Title: Section 759.9 - Medical record system

Effective Date

06/14/2017

759.9 Medical record system. The operator must:

(a) maintain a medical record system that contains a record, including a current comprehensive care plan for each registrant, in accordance with accepted professional standards of practice and the medical records system section of this Title. Each registrant's medical record shall contain, as a minimum:

(1) identification and admission information, including:

(i) all details of the referral and registration;

(ii)  identification of next of kin, family and sponsor;

(iii)  the person or persons to be contacted in the event of emergency;

(iv)  accident and incident reports;

(v)  non-medical correspondence and papers pertinent to the registrant’s participation in the program; and

(vi)  a fiscal record including copies of all agreements or contracts;

(2) documentation of medical examinations, progress notes and discharge summaries; and

(3) all other pertinent information related to the resident's care including record of attendance;

(b) develop and implement policies and procedures to ensure the confidentiality of all medical records.

Volume

VOLUME E (Title 10)

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