SECTION 340:100-3-40.1. Continuous medical record

  The continuous medical record provides an overview of the medical history and current medical problems of the service recipient.

(1)   Form 06HM039E, Continuous Medical Record, is:

(A)   initiated by the contract provider;

(B)   maintained in the home record per OAC 340:100-3-40; and

(C)   required for service recipients who receive:

(i)   community residential supports per OAC 340:100-5-22.1; or

(ii)   group home services per OAC 340:100-6.

(2)   Form 06HM039E includes, but is not limited to:

(A)   physician's current diagnosis from Form 06HM005E, Referral Form for Examination and Treatment; and

(B)   information regarding:

(i)   medical allergies;

(ii)   serious diseases and major illnesses;

(iii)   surgeries;

(iv)   fractures;

(v)   sutured lacerations;

(vi)   chronic medical conditions, such as seizures or diabetes; and

(vii)   reasons for emergency room visits or hospitalizations and diagnosis within the past year.

(3)   The health care coordinator:

(A)   or back-up as described in OAC 340:100-5-26, is responsible for making accurate entries on Form 06HM039E within 24 hours of occurrence by recording the information identified in OAC 340:100-3-40.1(2) from Form 06HM005E or other medical records; and

(B)   obtains the relevant historical information.

[Source: Added at 17 Ok Reg 3102, eff 6-7-00 (emergency); Added at 18 Ok Reg 1254, eff 5-11-01; Amended at 25 Ok Reg 986, eff 5-15-08]