1. (a) The resident records will contain sufficient information to identify the resident, his or her diagnosis or diagnoses and treatment, and to document the results accurately.

2. (b) Admission and discharge record:

   1. (1) Record number;
   2. (2) Date and time of admission;
   3. (3) Name;
   4. (4) Last known address;
   5. (5) Age;
   6. (6) Date of birth;
   7. (7) Sex;
   8. (8) Marital status;
   9. (9) Name, address, and telephone numbers of attending physician and dentist;
   10. (10) Name, address, and telephone number of next of kin;
   11. (11) Date and time of discharge or death; and
   12. (12) Admitting and final diagnosis.

3. (c) History and physical examination prior to admission:

   1. (1) Medical history;
   2. (2) Physical findings which includes a complete review of systems and diagnosis and or diagnoses; and
   3. (3) Date and signature of physician.

4. (d) Physician orders:

   1. (1) Date;

   2. (2) Orders for:

      1. (A) Medication;
      2. (B) Treatment;
      3. (C) Care;
      4. (D) Diet;
      5. (E) Restraints;
      6. (F) Extend of activity;
      7. (G) Therapeutic home visits;
      8. (H) Discharge; or
      9. (I) Transfer; and

   3. (3)

      1. (A) Telephone or verbal orders may be taken and written by licensed personnel and countersigned by the physician given the order within seven (7) days.
      2. (B) Telephone or verbal orders for restraints must be signed by the physician giving the order within five (5) days.

5. (e) Physician progress notes:

   1. (1) Written at the time of each visit;
   2. (2) Dated;
   3. (3) Signature of the physician; and

   4. (4) Written at least every:

      1. (A) Sixty (60) days on skilled care patients; and
      2. (B) One hundred twenty (120) days on others.

6. (f) Nursing notes:

   1. (1) Each entry will be dated and signed by the person making such entry;

   2. (2) PRN medications will be documented as to the:

      1. (A) Time given;
      2. (B) Amount given;
      3. (C) Reason given;
      4. (D) Results; and
      5. (E) Signature of person giving the medication;
   3. (3) Vital signs shall be taken and recorded on all patients as ordered by the attending physician, not less than weekly;
   4. (4) Date and time of all treatments and dressings;
   5. (5) Date and time of physician visits;

   6. (6) Complete record of all restraints, including:

      1. (A) Time of application and release;
      2. (B) Type of restraint; and
      3. (C) Reason for applying;
   7. (7) Record all incidents and accidents, and follow-up involving the resident;
   8. (8) The amount and type of bedtime nourishment taken by residents on calorie-controlled diets;
   9. (9) Condition on discharge or transfer;
   10. (10) Disposition of personal belongings and medications upon discharge;
   11. (11) Time of death and the name of person pronouncing the death of the resident and disposition of the body; and

   12. (12)

       1. (A) Heights and weights of the residents will be obtained at the time of admission to the facility.
       2. (B) Weights will then be recorded at least monthly.

7. (g) Discharge summaries should include:

   1. (1) Signature of the physician;
   2. (2) Admitting and final diagnosis;
   3. (3) Course of resident’s treatment and condition while in the nursing home;
   4. (4) Cause of death, if applicable; and
   5. (5) Disposition of resident, i.e., transfer to hospital, nursing home, mortuary, or home.

Codification Notes: “PRN” means pro re nata, a Latin phrase meaning “as necessary” or “as needed”.