Ill. Admin. Code tit. 77, § 300.1850 - Other Resident Record Requirements
This Section contains references to rules located in other Subparts that pertain to the content and maintenance of medical records.
a) The resident's record shall include facts
involved if the resident's discharge occurs despite medical advice to the
contrary, as required by Section
300.620(f) of
this Part.
b) The resident's record
shall identify the reasons for any order and use of safety devices or
restraints, as required by Sections
300.680(c) and
300.1040(d),
respectively, of this Part.
c) The
resident's record shall include information regarding the physician's
notification and response regarding any serious accident or injury, or
significant change in condition, as required by Section
300.1010(h) of
this Part.
d) The resident's record
shall contain the physician's permission, with contraindications noted, for
participation in the activity program, as required by Section
300.1410(d) of
this Part.
e) The records of
residents participating in work programs shall document the appropriateness of
the program for the resident and the resident's response to the program, as
described in Section 300.1430(e) of
this Part.
f) Telephone orders
shall be transcribed into the resident's medical record or a telephone order
form and signed by the nurse taking the order, as described in Section
300.1620(a)(2)
of this Part.
g) Documentation of
the review of medication order shall be entered in the resident's medical
record as described in Section
300.1620(b) of
this Part.
h) The resident's
medical record shall include notations indicating any release of medications to
the resident or person responsible for the resident's care, as described in
Section 300.1620(e) of
this Part.
i) Instances of
inability to implement a physician's medication order shall be noted in the
resident's medical record, as described in Section
300.1630(d) of
this part.
j) Medication errors and
drug reactions shall be noted in the resident's medical record as described in
Section 300.1630(e) of
this Part.
k) The resident's record
shall include the physician's diet order and observations of the resident's
response to the diet, as describe in Section
300.2040 of this Part.
l) The resident's record shall contain any
physician determinations that limit the resident's access to the resident's
personal property, as described in Section
300.3210(b) of
this Part.
m) The facility shall
comply with Section 300.3210(g) of
this Part, which requires that any medical inadvisability regarding married
residents residing in the same room be documented in the resident's
record.
n) The facility shall
permit each resident, resident's parent, guardian or representative to inspect
and copy the resident's medical records as provided by Section
300.3220(g) of
this Part.
o) Any resident transfer
or discharge mandated by the physical safety of other residents shall be
documented in the resident's medical record as required by Sections
300.3300(d) and
(g) of this Part.
p) Summaries of discussions and explanations
of any planned involuntary transfers or discharges shall be included in the
medical record of the resident that is to be involuntarily transferred or
discharged, as described in Section
300.3300(j) of
this Part.
Notes
Amended at 13 Ill. Reg. 4684, effective March 24, 1989
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