Iowa Code r. 481-70.25 - Participant documents
(1)
Documentation for each participant shall be maintained by the program and shall
include:
a. A participation record including
the participant's name, birth date, and home address; identification numbers;
date of beginning participation; name, address and telephone number of health
professional(s); diagnosis; and names, addresses and telephone numbers of
family members, friends or other designated people to contact in the event of
illness or an emergency;
b.
Application forms;
c. The initial
evaluations and updates;
d. A
nutritional assessment as necessary;
e. The initial individual service plan and
updates;
f. Signed authorizations
for permission to release medical information, photographs, or other media
information as necessary;
g. A
signed authorization for the participant to receive emergency medical care as
necessary;
h. A signed managed risk
policy and signed managed risk consensus agreements, if any;
i. When any personal or health-related care
is delegated to the program, the medical information sheet; documentation of
health professionals' orders, such as those for treatment, therapy, and
medication; and nurses' notes written by exception;
j. Medication lists, which shall be
maintained in conformance with 481-paragraph
67.5(2)"d";
k.
Advance health care directives as applicable;
l. A complete copy of the participant's
contractual agreement, including any updates;
m. A written acknowledgment that the
participant or the participant's legal representative, if applicable, has been
fully informed of the participant's rights;
n. A copy of guardianship, durable power of
attorney for health care, power of attorney, or conservatorship or other
documentation of a legal representative;
o. Incident reports involving the
participant, including but not limited to those related to medication errors,
accidents, falls, and elopements (such reports shall be maintained by the
program but need not be included in the participant's medical
record);
p. A copy of waivers of
admission or retention criteria, if any;
q. When the participant is unable to advocate
on the participant's own behalf or the participant has multiple service
providers, including hospice care providers, accurate documentation of the
completion of routine personal or health-related care is required on task
sheets. If tasks are doctor-ordered, the tasks shall be part of the medication
administration records (MARs); and
r. Authorizations for the release of
information, if any.
(2)
The program records relating to a participant shall be retained for a minimum
of three years after the discharge or death of the participant.
(3) All records shall be protected from loss,
damage and unauthorized use.
Notes
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