S.C. Code Regs. § § 61-97.700.701

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

Section 61-97.700.701 - Content

A. The Facility shall maintain an organized medical record for each Patient. All entries shall be permanently written, typed, or electronic media, authenticated by the author, and dated.

B. The medical record shall be current and contain: (II)

1. Face sheet;

a. identification data (name, date of birth, gender);

b. diagnosis;

c. primary care physician's name and phone number;

d. Responsible person or other individual to be contacted in case of emergency and phone number;

e. Patient's address and phone number; and

f. date of admission;

2. Orders from Physicians and other Authorized Healthcare Providers for at least one (1) year. Standing orders shall be updated on an Annual basis;

3. Documentation of Physician or other Authorized Healthcare Provider visits for at least one (1) year. Physician or other Authorized Healthcare Provider visits shall be made at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the patient is receiving in-facility dialysis. The Facility shall document each visit missed by the Patient;

4. Physician progress notes for Home Dialysis Patients shall be documented monthly;

5. Lab and x-ray reports;

6. Annual history and physical;

7. Social worker initial assessments, updates, and quarterly progress notes;

8. Dietary initial assessments, updates, and monthly progress notes;

9. Miscellaneous consultations, hospitalizations;

10. Current Individual Plan of Care;

11. Nurses' progress notes each time of dialysis for one (1) month;

12. Nurse's initial admission assessment;

13. Signed consent forms.

S.C. Code Regs. § 61-97.700.701

Added by State Register Volume 44, Issue No. 06, eff. 6/26/2020.