Ohio Admin. Code 3701-17-19 - Records and reports
(A) Nursing homes shall keep the following
records and such other records as the director may require:
(1) An individual medical record shall be
maintained for each resident . Such record shall be started immediately upon
admission of a resident to the home and shall contain the following:
(a) Admission record. Name, residence, age,
sex, race/ethnicity, religion, date of admission, name and address of nearest
relative or guardian, admission diagnoses from referral record and name of
attending
the
resident 's physician and, if applicable, other licensed health
professional acting within the applicable scope of practice.
(b) Referral record. All records, reports,
and orders which accompany the resident as required by rule
3701-17-10
of the Administrative Code.
(c)
Nursing notes and care notes. A note of the condition of the resident on
admission and subsequent notes as indicated to describe changes in condition,
unusual events or accidents. Other individuals rendering services to the
resident may enter notes regarding the services they render.
(d) Medication administration record. A
doctor's order sheet upon which orders are recorded and signed by the physician
or other licensed health professional acting within the applicable scope of
practice, including telephone orders as required by rule
3701-17-13 of
the Administrative Code; a nurse 's treatment sheet upon which all treatments or
medications are recorded as given, showing what was done or given, the date and
hour, and signed by the nurse giving the treatment or medication; or other
documentation authenticating who gave the medication or treatment.
(e) Resident progress notes. A sheet or
sheets upon which the doctor, dentist, advanced practice nurse and other
licensed health professionals may enter notes concerning changes in diagnosis
or condition of the resident. Resident refusal of treatment and services shall
also be documented in the progress notes.
(f) Resident assessment record. All
assessments and information required by rule
3701-17-10
of the Administrative Code.
(g)
Care plan. The plan of care required by rule
3701-17-14
of the Administrative Code.
(h)
Photograph. A photograph is only necessary for residents who have been
identified as being a elopement risk. The photograph of the resident shall be
updated annually.
(2)
The nursing home shall maintain all records required by state and federal laws
and regulations, as to the purchase, delivery, dispensing, administering, and
disposition of all controlled substances including unused portions.
(3) The nursing home shall maintain a record
of all residents admitted to or discharged from the nursing home .
(B) A record shall be kept showing
the name and hours of duty of all persons who work in the home . The nursing
home shall maintain each employee's current home address in its personnel
file.
(C) All records and reports
required under rules
3701-17-01 to
3701-17-26 of the
Administrative Code shall be prepared, maintained, filed, and transmitted when
required, and shall be made available for inspection at all times when
requested by the director or his authorized representative. The records may be
maintained in electronic format, microfilm, or other method that assures a true
and accurate copy of the records are available.
(1) The nursing home shall maintain the
records and reports required by paragraph(A)(1) of this rule in the following
manner:
(a) The home shall safeguard the
records and reports against loss, destruction, or unauthorized use and store
them in a manner that protects and ensures confidentiality.
(b) The home shall maintain the records and
reports for seven years following the date of the resident's discharge, except
if the resident is a minor, the records shall be maintained for three years
past the age of majority but not less than seven years.
(c) Upon closure of the home , the operator
shall provide and arrange for the retention of records and reports in a secured
manner for not less than seven years. The operator shall notify the director of
the location where the records will be stored.
(2) The nursing home shall maintain all other
records and reports required by rules
3701-17-01 to
3701-17-26 of the
Administrative Code for seven years.
(3) Upon the request of the resident
or former resident
, or the resident 's or former resident 's legal
representative, the nursing home shall provide:
(a) Access to medical and financial records
and reports pertaining to the resident within twenty-four hours, excluding
holidays and weekends; and
(b)
Photocopies of any records and reports, or portions thereof, at a cost not to
exceed the community standard for photocopying, unless otherwise specified by
law, upon two working days advanced notice.
(D) All records and reports required by
Chapter 3701-13 of the Administrative Code shall be maintained and made
available in accordance with that chapter.
(E)
Upon the change
of operator of a nursing home , the records required to be kept pursuant to this
rule shall be transferred to the new operator of the home .
Notes
Promulgated Under: 119.03
Statutory Authority: 3721.04
Rule Amplifies: 3721.04
Prior Effective Dates: 5/2/66, 3/1/1971, 3/8/81, 12/21/92, 9/5/97, 10/20/01, 4/1/12
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