(a)

1. (1) The facility must maintain a separate and distinct record for each resident.

2. (2) The record must contain:

   1. (A) The resident's name;
   2. (B) The resident's last address;
   3. (C) The date the resident began residing at the facility;
   4. (D) The name, office telephone number, and emergency telephone number of each physician who treats the resident;
   5. (E) The name, address, and telephone number of family members and the person identified by the resident who should be contacted in the event of an emergency or death of the resident;
   6. (F) All identification numbers, such as Medicaid, Medicare/Medipak, Social Security, Veterans Administration, and date of birth;
   7. (G) Any other information which the resident requests the home to keep on record;
   8. (H) A copy of the resident's signed resident rights statement;
   9. (I) A copy of the admission, transfer, and discharge agreements;
   10. (J) A written acknowledgement that the resident and/or responsible party have been notified of the charges for the services provided;
   11. (K)

(i) Information about any specific health problem of the resident which might be necessary in a medical emergency.

1. (ii)

(b) (b) If none, state "no known allergies";

1. (L) A brief medical history;

   1. (M) A list of all current medications kept by the facility for the resident;

   2. (N)

      1. (i) An entry shall be made at any time the resident's status changes or in the event of an unusual occurrence.
      2. (ii) This documentation shall include:

(b) (b) Illness;

1. (c) (c) Physician visits;

   1. (d) (d) Any problem with staff members or others;

(g) (g) Changes in the resident's condition;

1. (O) A copy of the completed assessment form done by a mental health service provider as appropriate;

   1. (P) A copy of court orders or letters of guardianship, if applicable; and
   2. (Q) The discharge date.

(b) The facility must maintain the resident's records in the following manner:

1. (1) Each resident shall have the right to inspect his or her records during normal business hours unless contraindicated by the attending physician;
2. (2) The facility must not disclose any resident records maintained by the facility to any person or agency other than the facility personnel or the Office of Long-Term Care except upon expressed written consent of the resident, unless the disclosure is required by state or federal law or regulation;
3. (3) Each facility must provide a locked file cabinet or locked room for keeping resident's medical, social, personal, and financial records; and
4. (4) The facility must maintain (on paper, microfilm, etc.) these records in an accessible manner for a period of five (5) years following the death or discharge of a resident.