Section 11-89-18 - Records and reports(a) Individual records shall be maintained for each resident. Upon admission or readmission, the facility shall maintain: (1) Records which identify the resident's name, social security number, marital status, date of birth, sex, next of kin or guardian, and religious preference, if any. A record of the address and telephone number of the referral agency or source by which the resident was admitted, the attending physician, dentist, and other medical or social service professionals who are currently involved in providing services to the resident, as well as a record of the agency responsible for financial payment, and the medical insurance plan;(2) A report of a medical examination current to within nine months and current diagnosis, physician's orders for medication, diet, special appliances and equipment, treatment, evaluations or direct service to be provided by a physical therapist, occupational therapist, or speech pathologist and a report of an examination for tuberculosis performed within the year prior to admission, height and weight and medical history;(3) Copies of the resident's individual plan; and(4) An inventory of money and valuables. This inventory shall be kept current.(b) During residence, records shall be maintained by the caregiver and shall include the following information: (1) Copies of physician's initial, annual and other periodic examinations, evaluations, medical progress notes, relevant laboratory reports, and a report of re-examination of tuberculosis;(2) Observations of the resident's response to medication, treatments, diet, provision of care, response to activities programs, indications of illness or injury, unusual skin problems, changes in behavior patterns, noting the date, time and actions taken, if any, which shall be recorded monthly or more often as appropriate but immediately when an incident occurs;(3) Entries by the caregiver describing treatments and services rendered;(4) Medications made available;(5) Physician's signed orders for diet, medications, special appliances, adaptive equipment, and treatments;(6) All recordings of temperature, pulse, respiration as ordered by a physician or as may appear to be needed. Physicians shall be promptly advised of any changes in physical or mental status;(7) Recording of resident's weight at least once a month, and more often when requested by a physician;(8) Notation of visits and consultations made to residents by other authorized personnel; and(9) Correspondence pertaining to the resident's physical and mental status.(c) Unusual incidents shall be noted in the resident's progress notes. An incident report of any bodily injury or other unusual circumstances affecting a resident which occurs within the home, on the premises, or elsewhere shall be submitted to the case manager within twenty-four hours from the time of the incident and shall be retained by the facility under separate cover, and shall be made available to the department and other authorized personnel. The resident's physician shall be called immediately if medical care is necessary.(d) When a resident is transferred, the caregiver shall provide a written transfer summary promptly to the receiving facility, which shall include: (1) The reason for the transfer;(2) Evidence of prior notice or the written consent of the resident's legal guardian, if any;(3) Current physical and mental status of resident; and(4) Current diet, medication, and activity orders signed by a physician. In the course of an emergency transfer, as much of the information required in section 11-89-21 shall be given as time permits.
(e) General rules regarding records: (1) All entries in the resident's records shall be written in blue or black ink, or typewritten, shall be legible, dated, and signed with full signature and title by the individual making the entry;(2) Erasures and white outs shall be not be permitted;(3) Symbols and abbreviations may be used in recording entries only if they conform to standard medical symbols or a legend is provided to explain them;(4) An area shall be provided for the safe and secure storage of residents' records which must be retained by the facility for periods as prescribed by state law; and(5) All records shall be complete and current and readily available for review by the department or any responsible placement agency.(f) All information contained in resident's record shall be treated by the staff as confidential. Written consent of the resident or resident's guardian, shall be required for the release of information to persons not otherwise authorized to receive it. Records shall be secured against loss, destruction, defacement, tampering, or use by unauthorized persons. There shall be written policies governing access to, duplication of, and release of any information from the resident's record. Records shall be readily accessible and available to authorized department personnel for the purpose of determining compliance with the provisions of this chapter.
(g) Miscellaneous records: (1) A permanent general register shall be maintained to record all admissions and discharges of residents;(2) When requested statistical information shall be provided to the department; and(3) Records of evacuation drills shall be available to the department for inspection.[Eff FEB 03 1992] (Auth: HRS §§ 321-9, 321-11, 321-15.9) (Imp: HRS § 321-15.9)