S.C. Code Regs. § § 61-78.800.802

Current through Register Vol. 48, No. 10, October 25, 2024

Section 61-78.800.802 - Content (II)

A. The Hospice shall initiate and maintain an organized record for each patient. The record shall contain sufficient documented information to identify the patient and verify appropriate care rendered. All entries shall be written legibly in ink or typed, signed, and dated.

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

1. Consultations by physicians or other authorized healthcare providers;

2. Orders for all medication, care, treatment, services, and procedures from physicians or other authorized healthcare providers shall be completed prior to, or at the time of admission, and updated when revised. Verbal orders received shall include the date of receipt of the order, description of the order, and identification of the individual receiving the order;

3. Care, treatment, and services provided;

4. Medications administered and procedures followed if an error is made, to include adverse reactions;

5. The Hospice Facility shall document medication administration by including medication name, dosage, mode of administration, date, time, and the signature of the individual administering or supervising the taking of the medication. Initials are acceptable when they can be identified readily by signatures;

6. Notes of observation;

7. Time and circumstances of death or of discharge or transfer, including condition at discharge or transfer.

S.C. Code Regs. § 61-78.800.802

Replaced and amended by State Register Volume 40, Issue No. 04, eff. 4/22/2016.