Haw. Code R. § 11-100.1-17 - Records and reports

(a) The licensee or primary care giver shall maintain individual records for each resident. On admission, readmission, or transfer of a resident there shall be made available by the licensee or primary care giver for the department's review:

(1) Documentation of primary care giver's assessment of resident upon admission;

(2) Recording of identifying information such as resident's name, social security number, racial extraction, marital status, date of birth, sex, and minister or religious denomination, and information about medical plan or coverage;

(3) Documentation of date of referral and admission, referral agency with address and telephone number, place or source from which admitted, physician, APRN, dentist, ophthalmologist, optometrist, psychiatrist, and all other medical or social service professionals who are currently treating the resident, next of kin, legal guardian, surrogate or other legally responsible agency;

(4) A report of a recent medical examination and current diagnosis taken within the preceding twelve months and report of an examination for tuberculosis. The examination for tuberculosis shall follow current departmental policies;

(5) Copy of advanced directive, as available;

(6) Physician or APRN signed orders for diet, medications, and treatments;

(7) Height and weight measurements taken; and

(8) A current inventory of money and valuables.

(b) During residence, records shall include:

(1) Annual physical examination and other periodic examinations, pertinent immunizations, evaluations, progress notes, relevant laboratory reports, and a report of annual re-evaluation for tuberculosis;

(2) A copy of advanced directives, as available;

(3) Progress notes that shall be written on a monthly basis, or more often as appropriate, shall include observations of the resident's response to medication, treatments, diet, care plan, any changes in condition, indications of illness or injury, behavior patterns including the date, time, and any and all action taken. Documentation shall be completed immediately when any incident occurs;

(4) Entries describing treatments and services rendered;

(5) Entries detailing all medications administered or made available;

(6) All recordings of temperature, pulse, respiration as ordered by a physician, APRN or as may appear to be needed. Physician or APRN shall be advised of any changes in physical or mental status promptly;

(7) Recording of resident's weight at least once a month, and more often when requested by a physician, APRN or responsible agency;

(8) Notation of visits and consultations made to resident by other professional personnel as requested by the resident or the resident's physician or APRN; and

(9) Correspondence pertaining to the resident's physical and mental status.

(c) Unusual incidents shall be noted in the resident's progress notes. An incident report of any bodily injury or other unusual circumstances affecting a resident which occurs within the home, on the premises, or elsewhere shall be made and retained by the licensee or primary care giver under separate cover, and shall be made available to the department and other authorized personnel. The resident's physician or APRN shall be called immediately if medical care may be necessary.

(d) When a resident is transferred, a written transfer summary shall be prepared, and a copy given promptly to the receiving facility, which shall include:

(1) The reason for the transfer;

(2) Evidence of prior notice or the written consent of the resident's family, legal guardian, surrogate or representative;

(3) Current physical and mental status of resident; and

(4) Current diet, medication, and activity orders signed by a physician or APRN.

(e) In the event of an emergency, an oral summary of the resident's condition shall be provided to the receiving facility, followed by a written transfer summary.

(f) General rules regarding records:

(1) All entries in the resident's record shall be written in black ink, or typewritten, shall be legible, dated, and signed by the individual making the entry;

(2) Symbols and abbreviations may be used in recording entries only if a legend is provided to explain them;

(3) An area shall be provided for safe and secure storage of resident's records which must be retained in the ARCH for periods prescribed by state law; and

(4) All records shall be complete, accurate, current, and readily available for review by the department or responsible placement agency.

(g) All information contained in the resident's record shall be confidential. Written consent of the resident, or resident's guardian or surrogate, shall be required for the release of information to persons not otherwise authorized to receive it. Records shall be secured against loss, destruction, defacement, tampering, or use by unauthorized persons. There shall be written policies governing access to, duplication of, and release of any information from the resident's record. Records shall be readily accessible and available to authorized department personnel for the purpose of determining compliance with the provisions of this chapter.

(h) Miscellaneous records

(1) A permanent general register shall be maintained to record all admissions and discharges of residents;

(2) When requested, statistical information shall be provided to the department;

(3) When day care clients are permitted in a Type I ARCH, records shall be maintained and include:

(A) Current physical examination and tuberculosis clearance;

(B) Medication and diet or supplement orders;

(C) Emergency information; and

(D) Progress notes, as appropriate.

Notes

Haw. Code R. § 11-100.1-17

[Eff SEP 18 2006] (Auth: HRS §§ 321-9, 321-10, 321-11, 321-15.6) (Imp: HRS §§ 321-10, 321-11, 321-15.6, 622-5(7), 622-5(8))