Cal. Code Regs. Tit. 22, § 78431 - Participant Health Records
(a) Each adult day health center shall
maintain a standard health record for each participant which includes, but is
not limited to:
(1) Identifying information
including:
(A) Name, address, telephone
number, birth date, Social Security and Medi-Cal numbers.
(B) Directions between home and adult day
health center.
(C) Name, address
and telephone number of personal physician; name, address and telephone number
of responsible person.
(2) Admission data including:
(A) Referral source.
(B) Reason for application as given by
referral source, participant and family or others.
(C) Number of days scheduled for attendance,
method of transportation and fee.
(3) Daily records of participant's attendance
and services utilized, including transportation.
(4) Records of:
(A) Referrals to other providers.
(B) Dates and substance of communication with
the participant's physician, family members and other persons providing
assistance.
(5)
Medication records.
(6) Progress
notes by providers of basic services.
(7) Assessment of the participant by the
multidisciplinary team.
(8) Record
of physician's health examination of participant.
(9) Individual plan of care.
(10) A written clearance by a physician for
participants who have been absent for 30 days due to
illness.
Notes
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No prior version found.