The record must
contain the following information:
complete initial screening assessment and general information form (SDS 902) as
described in OAR 411-051-0110
Documentation on form (SDS 913) that the licensee or administrator has informed
private-pay residents of the availability of a long-term care
form (SDS 0342A) that the licensee or administrator has oriented the resident
to emergency evacuation procedures as described in OAR
that the licensee or administrator has informed all residents of the right to
formulate an Advance Directive.
(A) Detailed records
and receipts, if the licensee manages or handles a resident's money. The
Resident Account Record (form SDS 713) or other expenditure forms may be used
if the licensee manages or handles a resident's money. The record must show
amounts and sources of funds received and issued to, or on behalf of, the
resident and be initialed by the person making the entry. Receipts must
document all deposits and purchases of $5 or more made on behalf of a
(B) Residency Agreement
signed and dated by the resident or the resident's representative may be kept
in a separate file, but must be made available for inspection by the
legal information, including, but not limited to:
(A) Medical history, if available.
(B) Current prescribing practitioner
(C) Nursing instructions,
delegations, and assessments, as applicable.
(D) Completed medication administration
records retained for at least the last six months or from the date of
admission, whichever is less. (Older records may be stored
(E) Copies of
Guardianship, Conservatorship, Advance Directive for Health Care, Power of
Attorney, and Physician's Order for Life Sustaining Treatment (POLST)
documents, as applicable.
(g) A complete, accurate, and current care
supports or eliminates any individually-based limitation, as described in OAR
(i) A copy of the
current house policies, as identified in the current Residency Agreement, and
the current Resident's Bill of Rights, signed and dated by the resident or the
SIGNIFICANT EVENTS AND INCIDENTS. A written report (using form SDS 344 or its
equivalent) of all significant incidents relating to the health or safety of
the resident, including how and when the incident occurred, who was involved,
what action was taken by the licensee and staff, as applicable, and the outcome
to the resident. A copy of the report must be sent to the resident's
representative, and case manager, if applicable.
(k) NARRATIVE OF RESIDENT'S PROGRESS.
Narrative entries describing each resident's progress must be documented at
least weekly and maintained in each resident's individual record. All entries
must be signed and dated by the person writing them.
(l) Non-confidential information or
correspondence pertaining to the care needs of the resident.
Falsifying records or causing another to
do so shall result in issuance of a mandatory civil penalty as described in OAR