Minnesota Administrative Rules

4658.0715 MEDICAL INFORMATION FOR CLINICAL RECORD.

A physician or physician designee must provide the following information for the clinical record:

A.

the report of the admission history and physical examination;

B.

the admitting diagnosis;

C.

a description of the general medical condition, including disabilities and limitations;

D.

a report of subsequent physical examinations;

E.

instructions relative to the resident's total program of care;

F.

written orders for all medications with stop dates, treatments, rehabilitations, and any medically prescribed special diets;

G.

progress notes;

H.

any advanced directives; and

I.

condition on discharge or transfer, or cause of death.

Statutory Authority:

MS s 144A.04; 144A.08; 256B.431

History:

20 SR 303

Published Electronically:

October 11, 2007