S.C. Code Regs. § § 61-103.700.701

Current through Register Vol. 48, 12, December 27, 2024

Section 61-103.700.701 - Content (II)

A. The facility shall initiate and maintain onsite an organized record for each resident. The record shall contain sufficient documented information to identify the resident and the agency and/or person responsible for each resident; support the diagnosis, secure the appropriate care and/or services as needed; justify the care and/or services provided to include the course of action taken and results; the symptoms or other indications of sickness or injury; changes in physical, mental, and/or behavioral condition; the response or reaction to care, medication, and diet provided; and promote continuity of care among providers, consistent with acceptable standards of practice. All entries shall be written legibly in ink, typed or electronic media, and signed and dated.

B. Specific entries and/or documentation shall include at a minimum:

1. Personal data sheet to include the following information, when obtainable: resident name; address including county; occupation; date of birth; sex; marital status; race; religion; county of birth; father's name; mother's maiden name; husband's or wife's name; health insurance number; provisional diagnosis; case number; days of care; Social Security number; name of the person providing information; name, address, and telephone number of person(s) to be notified in the event of an emergency; name and address of referral source; name of attending physician; and date and hour of admission;

2. Consultations by physicians or other authorized healthcare providers;

3. Orders and recommendations for all medication, care, services, procedures, and diet from physicians or other authorized healthcare providers, which shall be completed prior to, or within forty-eight (48) hours after admission, and thereafter as warranted. Verbal orders received shall be documented and include the date and time of receipt of the order, description of the order, and identification of the individual receiving the order;

4. Medication Administration Record (MAR) or similar document for recording of medications, treatments, and other pertinent data and procedures followed if an error is made;

5. Special examinations, if any, for example, consultations, clinical laboratory, x-ray and other examinations;

6. Notes of observation. In instances that involve significant changes in a resident's medical and/or mental condition and/or the occurrence of a serious incident, notes of observation shall be documented at least daily until the condition is stabilized and/or the incident is resolved. In all other instances, notes of observation for residents shall be documented;

7. Progress notes from all treatment services;

8. Time, circumstances, final diagnosis and condition of discharge, transfer, or death. In case of death, cause and autopsy findings, if an autopsy is performed;

9. Provisions for routine and emergency medical care, to include the name and telephone number of the resident's physician, plan for payment, and plan for securing medications;

10. Special information, such as proof of legal guardianship status, allergies, power of attorney, or responsible party;

11. Photograph of resident. Resident photographs shall be at a minimum two and one half inches by three and one half inches (2.5" by 3.5") in size, dated no more than twelve (12) months old, unless significant changes in appearance have occurred necessitating a more recent photograph;

12. Psychological testing;

13. Childhood development history;

14. Immunization history;

15. Psychosocial assessment, care plan;

16. Preadmission identification of current legal status, such as proof of custody;

17. Educational testing and prior educational records, when available upon request;

18. Treatment plan;

19. Activities assessment, care plan; and

20. Comprehensive treatment plan formulated by interdisciplinary team.

S.C. Code Regs. § 61-103.700.701

Replaced and amended by State Register Volume 40, Issue No. 06, eff. 6/24/2016.