A resident's clinical record must be started at admission and incorporated into a central unit record system. The clinical record must contain sufficient information to identify the resident, contain a record of resident assessments, the comprehensive plan of care, progress notes on the implementation of the care plan, and a summary of the resident's condition at the time of discharge.
Data collected must be timely, accurate, and complete. All entries must be entered, authenticated, and dated by the person making the entry. If a nursing home uses an electronic paperless means of storing the clinical record, the nursing home must comply with part 4658.0475. All entries must be made as soon as possible after the observation or treatment in order to keep the clinical record current. In cases where authentication is done electronically or by rubber stamp, safeguards to prevent unauthorized use must be in place, and a rubber stamp may be used only if allowed by the licensing rules for that health care professional. Nursing assistants may document in the nursing notes if allowed by nursing home policy.
All diagnoses and procedures must be accurately and comprehensively coded to ensure accurate resident medical profiles.
Identification information must be collected and maintained for each resident upon admission and must include, at a minimum:
the resident's legal name and preferred name;
social security number;
date and place of birth;
date and hour of admission;
advance directives, and Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, if any;
name, address, and telephone number of designated relative or significant other, if any;
name, address, and telephone number of person to be notified in an emergency;
legal representative, designated representative, or representative payee, if any;
religious affiliation, place of worship, and clergy member;
hospital preference; and
name of attending physician.
20 SR 303; 21 SR 196
October 11, 2007
Official Publication of the State of Minnesota
Revisor of Statutes