Minn. R. agency 144, ch. 4658, MEDICAL AND DENTAL SERVICES, pt. 4658.0715 - MEDICAL INFORMATION FOR CLINICAL RECORD

A physician or physician designee must provide the following information for the clinical record:

A. the report of the admission history and physical examination;

B. the admitting diagnosis;

C. a description of the general medical condition, including disabilities and limitations;

D. a report of subsequent physical examinations;

E. instructions relative to the resident's total program of care;

F. written orders for all medications with stop dates, treatments, rehabilitations, and any medically prescribed special diets;

G. progress notes;

H. any advanced directives; and

I. condition on discharge or transfer, or cause of death.

Notes

Minn. R. agency 144, ch. 4658, MEDICAL AND DENTAL SERVICES, pt. 4658.0715

20 SR 303

Statutory Authority: MS s 144A.04; 144A.08; 256B.431