1. A. Each resident's health record shall include written documentation of (i) the initial physical examination, (ii) an annual physical examination by or under the direction of a licensed physician including any recommendation for follow-up care, and (iii) documentation of the provision of follow-up medical care recommended by the physician or as indicated by the needs of the resident.

2. B. Each physical examination report shall include:

   1. 1. Information necessary to determine the health and immunization needs of the resident, including:

      1. a. Immunizations administered at the time of the exam;
      2. b. Vision exam;
      3. c. Hearing exam;
      4. d. General physical condition, including documentation of apparent freedom from communicable disease, including tuberculosis;
      5. e. Allergies, chronic conditions, and handicaps, if any;
      6. f. Nutritional requirements, including special diets, if any;
      7. g. Restrictions on physical activities, if any; and
      8. h. Recommendations for further treatment, immunizations, and other examinations indicated.
   2. 2. Date of the physical examination; and
   3. 3. Signature of a licensed physician, the physician's designee, or an official of a local health department.

3. C. Each resident's health record shall include:

   1. 1. Notations of health and dental complaints and injuries and a summary of the residents symptoms and the treatment given; and
   2. 2. A copy of the information required in subsection B of 6VAC35-101-950 (health care procedures).

Statutory Authority

§§ 16.1-309.9, 16.1-322.7, and 66-10 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 29, Issue 25, eff. January 1, 2014.