Section 481.58.15. Records.

       58.15(1) Resident admission record. The licensee shall keep a permanent record on all residents admitted to a nursing facility with all entries current, dated, and signed. This shall be a part of the resident clinical record. (III) The admission record form shall include:

        a.           Name and previous address of resident; (III)

        b.           Birth date, sex, and marital status of resident; (III)

        c.           Church affiliation; (III)

        d.           Physician’s name, telephone number, and address; (III)

        e.           Dentist’s name, telephone number, and address; (III)

        f.            Name, address, and telephone number of next of kin or legal representative; (III)

        g.           Name, address, and telephone number of person to be notified in case of emergency; (III)

        h.           Mortician’s name, telephone number, and address; (III)

        i.            Pharmacist’s name, telephone number, and address. (III)

       58.15(2) Resident clinical record. There shall be a separate clinical record for each resident admitted to a nursing facility with all entries current, dated, and signed. (III) The resident clinical record shall include:

        a.           Admission record; (III)

        b.           Admission diagnosis; (III)

        c.           Physical examination: The record of the admission physical examination and medical history shall portray the current medical status of the resident and shall include the resident’s name, sex, age, medical history, tuberculosis status, physical examination, diagnosis, statement of chief complaints, estimation of restoration potential and results of any diagnostic procedures. The report of the physical examination shall be signed by the physician. (III)

        d.           Physician’s certification that the resident requires no greater degree of nursing care than the facility is licensed to provide; (III)

        e.           Physician’s orders for medication, treatment, and diet in writing and signed by the physician quarterly; (III)

        f.            Progress notes.

       (1)             Physician shall enter a progress note at the time of each visit; (III)

       (2)             Other professionals, i.e., dentists, social workers, physical therapists, pharmacists, and others shall enter a progress note at the time of each visit; (III)

        g.           All laboratory, X-ray, and other diagnostic reports; (III)

        h.           Nurse’s record including:

       (1)             Admitting notes including time and mode of transportation; room assignment; disposition of valuables; symptoms and complaints; general condition; vital signs; and weight; (II, III)

       (2)             Routine notes including physician’s visits; telephone calls to and from the physician; unusual incidents and accidents; change of condition; social interaction; and P.R.N. medications administered including time and reason administered, and resident’s reaction; (II, III)

       (3)             Discharge or transfer notes including time and mode of transportation; resident’s general condition; instructions given to resident or legal representative; list of medications and disposition; and completion of transfer form for continuity of care; (II, III)

       (4)             Death notes including notification of physician and family to include time, disposition of body, resident’s personal possessions and medications; and complete and accurate notes of resident’s vital signs and symptoms preceding death; (III)

        i.            Medication record.

       (1)             An accurate record of all medications administered shall be maintained for each resident. (II, III)

       (2)             Schedule II drug records shall be kept in accordance with state and federal laws; (II, III)

        j.            Death record. In the event of a resident’s death, notations in the resident’s record shall include the date and time of the resident’s death, the circumstances of the resident’s death, the disposition of the resident’s body, and the date and time that the resident’s family and physician were notified of the resident’s death; (III)

        k.           Transfer form.

       (1)            The transfer form shall include identification data from the admission record, name of transferring institution, name of receiving institution, and date of transfer; (III)

       (2)             The nurse’s report shall include resident attitudes, behavior, interests, functional abilities (activities of daily living), unusual treatments, nursing care, problems, likes and dislikes, nutrition, current medications (when last given), and condition on transfer; (III)

       (3)             The physician’s report shall include reason for transfer, medications, treatment, diet, activities, significant laboratory and X-ray findings, and diagnosis and prognosis; (III)

        l.            Consultation reports shall indicate services rendered by allied health professionals in the facility or in health-centered agencies such as dentists, physical therapists, podiatrists, oculists, and others. (III)

       58.15(3) Resident personal record. Personal records may be kept as a separate file by the facility.

        a.           Personal records may include factual information regarding personal statistics, family and responsible relative resources, financial status, and other confidential information.

        b.           Personal records shall be accessible to professional staff involved in planning for services to meet the needs of the resident. (III)

        c.           When the resident’s records are closed, the information shall become a part of the final record. (III)

        d.           Personal records shall include a duplicate copy of the contract(s). (III)

       58.15(4) Incident record.

        a.           Each nursing facility shall maintain an incident record report and shall have available incident report forms. (III)

        b.           Report of incidents shall be in detail on a printed incident report form. (III)

        c.           The person in charge at the time of the incident shall prepare and sign the report. (III)

        d.           The report shall cover all accidents where there is apparent injury or where hidden injury may have occurred. (III)

        e.           The report shall cover all accidents or unusual occurrences within the facility or on the premises affecting residents, visitors, or employees. (III)

        f.            A copy of the incident report shall be kept on file in the facility. (III)

       58.15(5) Retention of records.

        a.           Records shall be retained in the facility for five years following termination of services. (III)

        b.           Records shall be retained within the facility upon change of ownership. (III)

        c.           Rescinded, effective 7/14/82.

        d.           When the facility ceases to operate, the resident’s record shall be released to the facility to which the resident is transferred. If no transfer occurs, the record shall be released to the individual’s physician. (III)

       58.15(6) Reports to the department. The licensee shall furnish statistical information concerning the operation of the facility to the department on request. (III)

       58.15(7) Personnel record.

        a.           An employment record shall be kept for each employee, consisting of the following information: name and address of employee, social security number of employee, date of birth of employee, date of employment, experience and education, references, position in the home, criminal history and dependent adult abuse background checks, and date and reason for discharge or resignation. (III)

        b.           The personnel records shall be made available for review upon request by the department. (III)