§ 2800.252. Content of resident records.
Each resident’s record must include the following information:
(1) Name, gender, admission date, birth date and Social Security number.
(2) Race, height, weight at time of admission, color of hair, color of eyes, religious affiliation, if any, and identifying marks.
(3) A photograph of the resident that is no more than 2 years old.
(4) A language, speech, hearing or vision need which requires accommodation or awareness of during oral or written communication.
(5) The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
(6) The name, address and telephone number of the resident’s physician or source of health care.
(7) The current and previous 2 years’ physician’s examination reports, including copies of the medical evaluation forms.
(8) A list of prescribed medications, OTC medications and CAM.
(9) Dietary restrictions.
(10) A record of incident reports for the individual resident.
(11) A list of allergies.
(12) Documentation of health care services and orders, including orders for the services of visiting nurse or home health agencies.
(13) The initial assessment, the preliminary support plan and the most current version of the annual assessment.
(14) A final support plan.
(15) Applicable court order, if any.
(16) The resident’s medical insurance information.
(17) The date of entrance into the residence, relocations and discharges, including the transfer of the resident to other residences owned by the same legal entity.
(18) An inventory of the resident’s personal property as voluntarily declared by the resident upon admission and voluntarily updated.
(19) An inventory of the resident’s property entrusted to the administrator for safekeeping.
(20) The financial records of residents receiving assistance with financial management.
(21) The reason for termination of services or transfer of the resident, the date of transfer and the destination.
(22) Copies of transfer and discharge summaries from hospitals, if available.
(23) If the resident dies in the residence, a copy of the official death certificate.
(24) Signed notification of rights, grievance procedures and applicable consent to treatment protections specified in § 2800.41 (relating to notification of rights and complaint procedures).
(25) A copy of the resident-residence contract.
(26) A termination notice, if any.
(27) A record relating to any exception request under § 2800.229 (relating to excludable conditions; exceptions).
(28) Ongoing resident progress notes.
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