Section 22-B3821. RESIDENT RECORDS

 

3821.1Each MHCRF shall maintain a permanent record on each resident, which shall be retained for at least five (5) years after the resident's discharge or death.

 

3821.2Each resident's record shall be current with each entry dated and signed with the full name of the recordkeeper, and shall include the following information on each resident:

 

(a)Administrative information, including name, date of birth, sex and social security number, and marital status;

 

(b)Medical insurance numbers, including Medicare and Medicaid, if any;

 

(c)Date of admission, psychological/psychiatric evaluation and admitting diagnoses;

 

(d)Date of discharge or death, discharge reason and final diagnosis;

 

(e)Names, addresses, and telephones numbers of the resident’s legal guardian, CMHS designated case manager, if any, and next-of-kin;

 

(f)Names, addresses and telephone numbers of the personal physician and dentist;

 

(g)Religious affiliation, if any, including the name and telephone number of the resident's minister, priest, or rabbi;

 

(h)Medical history, including the resident's allergies and vaccine histories;

 

(i)A current record of any funds managed by the residence for the resident's benefit pursuant to §3816 of this chapter;

 

(j)Medication, diet, treatment and any other procedures that are required for the safety and well-being of the resident;

 

(k)A daily record of each medication and treatment given;

 

(l)Notes or incident reports of any serious illness, accident or unusual occurrence, including medication errors or adverse reaction which shall include the date, time and description of the incident or accident; and

 

(m)Source of the referral to the MHCRF.

 

3821.3Each entry in the record shall be legible, current, in ink, dated and signed by the transcriber with his or her position identified. Errors shall be corrected by crossing out the incorrect information, but may not be erased.

 

source

Final Rulemaking published at 42 DCR 569, 591 (January 27, 1995).