1. (1) The licensee shall implement a medical records system to ensure complete and accurate retrieval and compilation of information.

2. (2)(a) The administrator shall designate an employee to be responsible and accountable for the processing of medical records.

   1. (b) The administrator shall ensure that a registered record administrator (RRA) or accredited record technician (ART) directs the medical records department.
   2. (c) If an RRA or ART is not employed at least part-time, the administrator shall consult with an RRA or ART according to the needs of the facility, and no less than semi-annually.

3. (3) The licensee shall ensure resident medical records are:

   1. (a) kept for at least seven years and medical records of minors are kept until the age of 18 plus four years, but in no case less than seven years;
   2. (b) kept, stored, and safeguarded from loss, defacement, tampering, and damage from fires and floods; and
   3. (c) protected against access by unauthorized individuals.

4. (4) The licensee shall maintain an individual medical record for each resident that contains written documentation of:

   1. (a) a copy of an advanced directive, if a resident has one;
   2. (b) a discharge summary for the resident to include a note of condition, instructions given, and referral as appropriate;
   3. (c) a history and physical examination up-to-date at the time of the resident's admission;
   4. (d) a pre-admission screening;
   5. (e) a record of assessments, including the comprehensive resident assessment, care plan, and services provided;
   6. (f) a record of medications and treatments administered;
   7. (g) a service agreement if respite services are provided;

   8. (h) an admission record with demographic information and resident identification data;

      1. (i) orders by clinical staff members;
   9. (j) information pertaining to incidents, accidents, and injuries;

   10. (k) informative progress notes by staff to record changes in the resident's condition and response to care and treatment in accordance with the care plan;

       1. (l) laboratory and radiology reports;
   11. (m) monthly nursing summaries;
   12. (n) nursing notes;
   13. (o) physician treatment orders;
   14. (p) quarterly resident assessments;
   15. (q) records made by staff regarding daily care of the resident; and
   16. (r) written and signed informed consent.
5. (5) The licensee shall ensure any entries into the medical record are authenticated including date, name or identifier initials, and job title of the person making the entries.
6. (6) The licensee shall ensure resident respite records are maintained within the facility.

KEY: health care facilities

Date of Last Change: February 18, 2025

Notice of Continuation: January 24, 2022

Authorizing, and Implemented or Interpreted Law: 26B-2-202