SECTION 310:680-3-7. Resident records  


Latest version.
  • (a)   All current documents which relate to the residents must be kept in the residential care home. Other records may be kept in the central business office or other location, but must be made available upon request by the Department.
    (b)   Every resident record shall be written in ink and include as a minimum, the following information:
    (1)   Resident's name.
    (2)   Date of Birth.
    (3)   Person to contact in case of emergency.
    (4)   Written authorization for emergency medical/dental services signed by the resident or responsible party.
    (5)   Medical summary to include quarterly weight of resident, medications, and dosages.
    (6)   The name, address, and telephone numbers of resident's physician and dentist.
    (7)   A record of the resident's illnesses, accidents, and unusual occurrence while a resident of the home.
    (8)   The legal status of the resident.
    (9)   An accounting of the resident's funds received and/or distributed by the residential care home.
    (c)   All persons having access to the records shall strictly adhere to confidentiality of records.
    (d)   Resident records shall be maintained in a lockable container or a specific lockable area.
    (e)   Only individuals authorized by the residential care home shall have access to resident records.