1. (a) Each center shall maintain a complete health record for each participant in the program in the format established by the Department. Each medical record shall include, but is not limited to:

   1. (1) Identifying information including:

      1. (A) Name, address, telephone number, sex, age, ethnic background, Social Security and Medi-Cal numbers.
      2. (B) Name, address and phone number of responsible person.

   2. (2) Admission data including:

      1. (A) Referral source.
      2. (B) Reason for application as given by referral source, participant and family or others.
      3. (C) Date of entry into the program, number of days scheduled for attendance, method of transportation and fee if non-Medi-Cal.
   3. (3) Signed Agreement of Participation.
   4. (4) Daily records of participant's attendance and services utilized, including transportation.

   5. (5) Records shall be maintained of:

      1. (A) Referrals to other providers.
      2. (B) Dates and substance of communications with the participants' physician, family members and other persons providing assistance.
   6. (6) Medication records.
   7. (7) Medication errors and drug reactions shall be recorded with notation of action taken.
   8. (8) Progress notes by involved personnel.
   9. (9) Assessment of the participants by the multidisciplinary team.
   10. (10) Physician examination and medical history.
   11. (11) Individual plan of care.

Note: Authority cited: Chapter 1066, Statutes of 1977. Reference: Chapter 1066, Statutes of 1977.

History

1. Amendment of subsection (a)(1) filed 9-19-79; effective thirtieth day thereafter (Register 79, No. 38).