Section 330.1750  Other Resident Record Requirements

This Section contains references to rules located in other Subparts that pertain to the content and maintenance of medical records.

a)         The resident's record shall include information regarding the physician's notification and response regarding any serious accident or injury, or significant change in condition, as required by Section 330.1110(e) of this Part.

b)         The resident's record shall identify the reasons for any order and use of safety devices or restraints, as required by Section 330.1140(d) of this Part.

c)         The resident's record shall contain the physician's permission, with contraindications noted, for participation in the activity program, as required by Section 330.1310(d) of this Part.

d)         The records of residents participating in work programs shall document the appropriateness of the program for the resident and the resident's response to the program, as described in Section 330.1320(d) of this Part.

e)         Documentation of the review of the medication regimen by the attending physician shall be entered in the resident's record, as required by Section 330.1510(c)(2) of this Part.

f)         The resident's record shall include the physician's diet order and observations of the resident's response to the diet, as described in Section 330.1940 of this Part.

g)         The resident's record shall contain any physician determinations that limit the resident's access to the resident's personal property, as described in Section 330.4210(b) of this Part.

h)         The facility shall comply with Section 330.4210(g) of this Part, which requires that any medical inadvisability regarding married residents residing in the same room be documented in the resident's record.

i)          The facility shall permit each resident, resident's parents, guardian or representative to inspect and copy the resident's medical records as provided by Section 330.4220(g) of this Part.

j)          Any resident transfer or discharge mandated by the physical safety of other residents shall be documented in the resident's medical record as required by Section 330.4300(d) and (g) of this Part.

k)         Summaries of discussions and explanations of any planned involuntary transfers or discharges shall be included in the medical record of the resident that is to be involuntarily transferred or discharged, as described in Section 330.4300(j) of this Part.

(Source:  Amended at 13 Ill. Reg. 6562, effective April 17, 1989)