§ 77141. Health Record Content.

(a) Each patient's health record shall consist of at least the following:

(1) Admission and discharge record identification data including, but not limited to, the following:

(A) Name.

(B) Address on admission.

(C) Patient identification number.

(D) Social Security number.

(E) Date of birth.

(F) Sex.

(G) Marital status.

(H) Legal status.

(I) Religion (optional on part of patient).

(J) Date of admission.

(K) Date of discharge.

(L) Name, address and telephone number of person or agency responsible for patient.

(M) Initial diagnostic impression.

(N) Discharge or final diagnosis.

(O) Disposition, including aftercare arrangements, plus a copy of the aftercare plan prepared pursuant to section 1284, Health and Safety Code, if the patient was placed in the facility under a county Short-Doyle plan.

(2) Mental status.

(3) Medical history and physical examination.

(4) Dated and signed observations and progress notes recorded as often as the patient's condition warrants by the person responsible for the care of the patient.

(5) Any necessary legal authorization for admission.

(6) Consultation reports.

(7) Medication treatment and diet orders.

(8) Social service evaluation, if applicable.

(9) Psychological evaluations, if applicable.

(10) Dated and signed patient care notes including, but not limited to, the following:

(A) Concise and accurate records of nursing care provided.

(B) Records of pertinent nursing observations of the patient and the patient's response to treatment.

(C) The reasons for the use of and the response of the patient to PRN medication administered and justification for withholding scheduled medications.

(D) Record of type of restraint, including time of application and removal as outlined in section 77103.

(11) Rehabilitation evaluation, if applicable.

(12) Interdisciplinary treatment plan.

(13) Progress notes including the patient's response to medication and treatment rendered and observation(s) of patient by all members of treatment team providing services to the patient.

(14) Medication records including name, dosage and time of administration of medications and treatments given. The route of administration and site of injection shall be recorded if other than by oral administration.

(15) Treatment records including group and individual psychotherapy, occupational therapy, recreational or other therapeutic activities provided.

(16) Vital sign sheet.

(17) Consent forms as required, signed by patient or person responsible for patient.

(18) All dental records, if applicable.

(19) Reports of all laboratory tests ordered.

(20) Reports of all cardiographic or encephalographic tests performed.

(21) Reports of all X-ray examinations ordered.

(22) All reports of special studies ordered.

(23) Acknowledgement in writing of patient's rights, as required in section 77099, signed by patient or person responsible for the patient.

(24) Denial of patient rights documentation.

(25) A discharge summary prepared by the admitting practitioner which shall briefly recapitulate the significant findings and events of the patient's treatment, his/her condition on discharge and the recommendation and arrangements for future care.

HISTORY

1. New section filed 4-15-87, operative 5-15-87; (Register 87,No. 16).

2. Change without regulatory effect filed 7/2/90 pursuant to section 100, title 1, California Code of Regulations (Register 90, No. 35).

Note

Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1275.1, Health and Safety Code.