N.M. Admin. Code § 8.370.16.32 - MEDICAL RECORDS - CONTENT
Except for persons admitted for short-term care, each resident's medical record shall contain:
A. Identification and summary
sheet:
B. Physician's
documentation:
(1) An admission medical
evaluation by a physician, including:
(a) a
summary of prior treatment;
(b)
current medical findings;
(c)
diagnosis at the time of admission to the facility;
(d) the resident's rehabilitation
potential;
(e) the results of the
required physical examination;
(f)
level of care.
(2) All
physician's orders including:
(a) admission to
the facility;
(b) medications and
treatments;
(c) diets;
(d) rehabilitative services;
(e) limitations on activities;
(f) restraint orders;
(g) discharge or transfer orders.
(3) Physician progress notes
following each visit.
(4) Annual
physical examination.
(5) Alternate
visit schedule, and justification for such alternate visits, not to exceed 90
days.
C. Nursing service
documentation:
(1) An assessment of the
resident's nursing needs.
(2)
Initial nursing care plan and any revisions.
(3) Nursing notes are required as follows:
(a) for residents requiring skilled care, a
narrative nursing note shall be required as often as needed to document the
resident's condition, but at least weekly; and
(b) for residents not requiring skilled care,
a narrative nursing note shall be required as often as needed to document the
resident's condition, but at least monthly.
(4) In addition to the nursing care plan,
nursing documentation describing:
(a) the
general physical and mental condition of the resident, including any unusual
symptoms or actions;
(b) all
incidents or accidents including time, place, injuries or potential
complications from injury or accident, details of incident or accident, action
taken, and follow-up care;
(c) the
administration of all medications, the need for PRN medications and the
resident's response, refusal to take medication, omission of medications,
errors in the administration of medications, and drug reactions;
(d) food intake, when the monitoring of
intake is necessary;
(e) fluid
Intake when monitoring of intake is necessary;
(f) any unusual occurrences of appetite or
refusal or reluctance to accept diets;
(g) summary of restorative nursing measures
which are provided;
(h) summary of
the use of physical and chemical restraints;
(i) other non-routine nursing care
given;
(j) the condition of a
resident upon discharge; and
(k)
the time of death, the physician called, and the person to whom the body was
released.
D.
Social services records:
(1) a social history
of the resident; and
(2) notes
regarding pertinent social data and action taken.
E. Activities records: Documentation of
activities programming, a history and assessment, a summary of attendance, and
quarterly progress notes.
F.
Rehabilitative services:
(1) An evaluation of
the rehabilitative needs of the resident.
(2) Plan of treatment.
(3) Progress notes detailing treatment given,
evaluation, and progress.
G. Dietary assessment: Record of the dietary
assessment.
H. Dental services:
Summary of all dental services resident has received.
I. Diagnostic services: Records of all
diagnostic tests performed during the resident's stay in the
facility.
J. Plan of care: Plan of
care which includes integrated program activities, therapies and treatments
designed to help each resident achieve specific goals as developed by an
interdisciplinary team.
K.
Authorization or consent: A photocopy of any court order, power of attorney or
living will authorizing another person to speak or act on behalf of the
resident and any resident consent forms.
L. Discharge or transfer information:
Documents, prepared upon a resident's discharge or transfer from the facility,
summarizing, when appropriate:
(1) current
medical finding and condition;
(2)
final diagnosis;
(3) rehabilitation
potential;
(4) a summary of the
course of treatment;
(5) nursing
and dietary information;
(6)
ambulation status;
(7)
administrative and social information; and
(8) needed continued care and
instructions.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.