6 Va. Admin. Code § 35-101-1030

Current through Register Vol. 41, No. 8, December 2, 2024

Section 6VAC35-101-1030 - Residents' health care records

A. Each resident's health record shall include written documentation of (i) the initial physical examination, (ii) an annual physical examination by or under the direction of a licensed physician including any recommendation for follow-up care, and (iii) documentation of the provision of follow-up medical care recommended by the physician or as indicated by the needs of the resident.

B. Each physical examination report shall include:

1. Information necessary to determine the health and immunization needs of the resident, including:

a. Immunizations administered at the time of the exam;

b. Vision exam;

c. Hearing exam;

d. General physical condition, including documentation of apparent freedom from communicable disease, including tuberculosis;

e. Allergies, chronic conditions, and handicaps, if any;

f. Nutritional requirements, including special diets, if any;

g. Restrictions on physical activities, if any; and

h. Recommendations for further treatment, immunizations, and other examinations indicated.

2. Date of the physical examination; and

3. Signature of a licensed physician, the physician's designee, or an official of a local health department.

C. Each resident's health record shall include:

1. Notations of health and dental complaints and injuries and a summary of the residents symptoms and the treatment given; and

2. A copy of the information required in subsection B of 6VAC35-101-950 (health care procedures).

6 Va. Admin. Code § 35-101-1030

Derived from Virginia Register Volume 29, Issue 25, eff. January 1, 2014.

Statutory Authority

§§ 16.1-309.9, 16.1-322.7, and 66-10 of the Code of Virginia.