6 Colo. Code Regs. § 1011-1 Chapter 08 Part 11

Current through Register Vol. 47, No. 11, June 10, 2024

Part 11 - Resident Records

11.1 All records specifically required by these standards shall be made available to the Department for purposes of enforcing these regulations. If records are maintained electronically, they shall be made available to the Department in a manner that allows for a timely, efficient, and complete review.

11.2 Initial Record Requirements

(A) The following minimum information shall be recorded in the resident's program or medical record upon admission to the facility for persons with intellectual or developmental disabilities:

(1) Name, previous address, and birth date;

(2) Name, address, and phone number of legal guardian (if any), person to contact in an emergency, primary care practitioner, dentist, and case manager; and

(3) Special needs, allergies, special diet requirements, and current medication. If a resident has an allergy to any substance, a notice shall be placed in a conspicuous place on the resident's record.

(B) To the extent possible, the following shall also be obtained:

(1) The results of assessments conducted within the previous 12 months;

(2) All service plans, as appropriate, developed within the previous 12 months;

(3) Record of prescriptions of medications prescribed within the previous 12 months;

(4) Dates and descriptions of illnesses, accidents, significant changes of condition, treatments thereof, and immunizations for the previous 12 months;

(5) Summary of hospitalizations for the previous 12 months, to include recommendations for follow-up and treatment;

(6) Any other information relevant to the health of the resident; and

(7) Individual interests and preferences, including community activities.

11.3 Continuing Record Requirements

(A) Each facility shall maintain current and accurate program and medical records for individual residents that also contain:

(1) All information required by Part 11.1 of this chapter;

(2) A record of the use of the resident's funds including all debits, credits, and a description of purchases if supervised by the licensee;

(3) Current service plans, as appropriate, along with documentation of their implementation and progress toward meeting the goals;

(4) Documentation of resident interaction in the community, including activities offered and resident participation;

(5) Current photo of resident;

(6) General physical characteristics;

(7) General description of personality characteristics;

(8) Quarterly weight and annual height measurement;

(9) Records of interventions and treatments provided by practitioners, therapists, nurses, and other professional staff;

(10) Records of prescriptions ordered and medication administered in the previous 12 months;

(11) Date, time, and circumstances of resident's death, when applicable; and

(12) Documentation related to special diets, as required in Part 13.

(B) All entries in any resident record shall be dated and authenticated. Acceptable authentication shall be the staff's written signature, identifiable initials, computer key, or other appropriate technological means.

11.4 Medical Record Retention

(A) Medical records are those records pertaining to the health status and related medical services and treatments of the resident. Such records do not include documents involving services and programs.

(B) All medical records for adults (persons eighteen (18) years of age or older) shall be retained for no less than ten (10) years after the last date of service or discharge from the facility. All medical records for minors shall be retained after the last date of service or discharge from the facility for the period of minority plus ten (10) years.

6 CCR 1011-1 Chapter 08 Part 11