S.C. Code Regs. § ch. 61, 61-125, 61-125.700, 61-125.701

Current through Register Vol. 48, No. 11, November 22, 2024

Subsection 61-125.701 - Content. (II)

A. The facility shall initiate and maintain on site an organized record for each patient. The record shall contain sufficient documented information to identify the patient and the agency and/or person responsible for each patient; support the diagnosis and secure the appropriate care and services (as needed); justify the care and services provided to include the course of action taken and results; the symptoms or other indications of sickness or injury; changes in physical and/or mental condition; the response and/or reaction to care, medication, and diet provided; and promote continuity of care among providers, consistent with acceptable standards of practice. All entries shall be written legibly in ink, typed or electronic media, and signed, and dated.

B. If the facility permits any portion of a patient's record to be generated by electronic or optical means, there shall be policies and procedures to prohibit the use or authentication by unauthorized users.

C. Specific entries and documentation shall include at a minimum:

1. Consultations by physicians or other authorized healthcare providers;

2. Signed and dated orders and recommendations for all medication, care, services, procedures, and diet from physicians or other authorized healthcare providers, which shall be completed prior to, or at the time of admission, and subsequently, as warranted; (I)

3. Intake screening and initial physical assessment completed by a nurse;

4. Signed and dated original consent for treatment; (I)

5. The report of the mental status examination and other mental health assessments, as appropriate;

6. Daily progress notes by the direct care staff involved in the treatment of the patient, as applicable, to include documentation of significant behavioral events and actions taken by staff; and

7. Medication management and administration, and treatment records.

S.C. Code Regs. ch. 61, 61-125, 61-125.700, 61-125.701

Added by State Register Volume 43, Issue No. 05, eff. 5/24/2019.