Section 73547 - Content of Health Records(a) A facility shall maintain for each patient a health record which shall include the following: (2) Drug and treatment orders.(4) Progress notes written at the time of visit by professional personnel in attendance to the patient.(5) Nurses' notes which shall include: (A) Narrative notes made by nurses' aides when appropriate, and after such aides have been properly instructed. They shall include: 1. Care and treatment done with and for the patient.2. Patients' reactions to care and treatment.3. Daily observation of how the patient looks, feels, reacts, interacts, degree of dependency and motivation towards improved health.(B) Meaningful and informative nurses' progress notes written by licensed nurses as often as the patient's condition warrants. However, weekly nurses' progress notes shall be written by licensed personnel on each patient and shall be specific to the psychological, emotional, social, spiritual, recreational needs and related to the patient care plans. Progress notes reflecting observations of the patient's response to his environment, physical limitations, independent activities, dependency status, behavioral changes, skin problems, dietary problems and restorative measures to characterize the functional status of progression and/or regression.
(C) Name, dosage and time of administration of drugs, the route of administration if other than oral and site of injection. If the scheduled time is indicated on the record the initial of the person administering the dose shall be recorded, provided that the drug is given within one hour of the scheduled time. If the scheduled time is not recorded, the person administering the dose shall record both his initials and the time of administration.(D) Justification for and the results of the administration of all P.R.N. medications and the withholding of scheduled medications.(E) Record of type of restraint and time of application and removal. The time of application and removal shall not be required for soft tie restraints used for the support and protection of the patient.(F) Medications and treatments administered and recorded as prescribed.(6) Current history and physical examination or appropriate health evaluation.(7) Temperature, pulse and respiration where indicated.(8) Laboratory reports of all tests prescribed and completed.(9) Reports of all X-rays prescribed and taken.(10) Condition and diagnosis of patient at time of discharge and final disposition.(11) Orders provided by a licensed healthcare practitioner acting within the scope of his or her professional licensure, including drug, treatment and diet orders signed on each visit. Orders provided by the licensed healthcare practitioners acting within the scope of his or her professional licensure recapitulated as appropriate.(12) Observation and information pertinent to the dietetic treatment recorded in the patient's health record by the dietitian or nurse. Pertinent dietary records shall be included in patient's transfer records to ensure continuity of nutritional care.(13) Consent forms for prescribed treatment and medication.(14) An inventory of all patients' personal effects and valuables made upon admission and discharge. The inventory list shall be signed by a representative of the facility and the patient or his authorized representative with one copy to be retained by each.Cal. Code Regs. Tit. 22, § 73547
1. Amendment of subsections (a)(5)(A)3., (a)(5)(E) and (a)(11) and new NOTE filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10). Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
1. Amendment of subsections (a)(5)(A)3., (a)(5)(E) and (a)(11) and new Note filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).