Section 11-98-12 - Minimum standards for licensure; services Individual records shall be kept on each resident which contain the following:
(1) Within twenty-one days of admission, a report of a resident's medical examination or written evidence of a physical examination within the prior twelve months shall be on file;(2) A report of a tuberculin skin test. If the skin test is positive, or known to be positive, there shall be documentation that appropriate medical follow-up has been obtained;(3) Information on any necessary special arrangements for emergency medical care;(4) Information pertinent to special diet treatment;(5) Documentation that a physician was consulted within five days of admission as well as for all significant illnesses and injuries;(6) Dental treatment documentation for any resident requiring dental care;(7) Identification and summary information including resident's name, Social Security number, marital status, veteran's status, date of birth, sex, home address, telephone number of referral agency and next of kin or other legally responsible person;(8) Within thirty days after admission, a written individualized rehabilitation plan rich specific objectives which are measurable and subject to evaluation shall be prepared by an appropriate rehabilitation staff in cooperation with each resident. The plans shall include: (A) Those services planned for meeting the resident's needs.(B) Referrals for services not provided by the program.(C) How the resident viii participate in the development of the plan.(D) Regular review and necessary update by staff and resident at least monthly.(E) The staff person responsible for monitoring the plan implementation.(9) Monthly observations of the resident's response to the rehabilitation plan;(10) Observations of unusual response to medication or diet with evidence that a report to a physician was made immediately upon occurrence;(11) Height and weight, which shall be recorded, upon admission and thereafter, quarterly;(12) Any period of unauthorized absence from the facility;(13) Any correspondence pertaining to the resident;(14) A complete record of each medication utilized by the resident;(15) Any significant change in the resident's behavior pattern noted at the time of occurrences-including date, time and action taken;(16) Should vital signs be ordered by a physician, notations of temperature, pulse and respiration shall be recorded and the physician notified immediately in case of abnormality;(17) Complete financial records and monetary transfers between the residents and the facility;(18) A discharge summary or a transfer summary including the following: (A) The reason for the discharge or transfer, if identifiable.(B) Documentation that a guardian, when applicable, B2 has been notified prior to discharge or transfer. This provision may be waived in emergency situations but in this case the guardian must be notified as soon as practical. If the resident leaves without permission of the administrator, the guardian shall be notified promptly.(C) Current physical and emotional status report of the resident.(D) Plans or goals for the resident.(E) Current diet, medication, and activity as applicable.[Eff MAR 10 1986] (Auth: HRS §§ 321-9, 321-10) (Imp: HRS §§ 321-10, 92E-2, 92E-4, 92E-5, 378-2, 622-57, Pub. L. 88-352 (1964) , Pub. L. 95-555 (1978))