The resident medical file

The resident medical file

In addition to maintaining a financial record on each resident you must also keep a healthcare record for each resident who receives care services in your community. This should be an all-encompassing medical record that is easily accessible to care team members in the community to provide them with knowledge of care needs for each resident. Check out the following regulation provided by Arizona BRFL for what is to be included in the healthcare record as well as how to safely store and maintain said record:

R9-10-811. Medical Records

A manager shall ensure that:
A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1;
An entry in a resident’s medical record is:
Only recorded by an individual authorized by policies and procedures to make the entry;
Dated, legible, and authenticated; and
Not changed to make the initial entry illegible;
If a rubber-stamp signature or an electronic signature is used to authenticate an order, the individual whose signature the rubber-stamp signature or electronic signature represents is accountable for the use of the rubber-stamp signature or electronic signature;
A resident’s medical record is available to an individual:
Authorized according to policies and procedures to access the resident’s medical record;
If the individual is not authorized according to policies and procedures, with the written consent of the resident or the resident’s representative; or
As permitted by law; and
A resident’s medical record is protected from loss, damage, or unauthorized use.
If an assisted living facility maintains residents’ medical records electronically, a manager shall ensure that:
Safeguards exist to prevent unauthorized access, and
The date and time of an entry in a resident’s medical record is recorded by the computer’s internal clock.
A manager shall ensure that a resident’s medical record contains:
Resident information that includes:
The resident’s name, and
The resident’s date of birth;
The names, addresses, and telephone numbers of:
The resident’s primary care provider
Other persons, such as a home health agency or hospice service agency, involved in the care of the resident; and
An individual to be contacted in the event of emergency, significant change in the resident’s condition, or termination of residency;
If applicable, the name and contact information of the resident’s representative and:
The document signed by the resident consenting for the resident’s representative to act on the resident’s behalf; or
If the resident’s representative:
Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36- 3282, a copy of the health care power of attorney or mental health care power of attorney; or
Is a legal guardian, a copy of the court order establishing guardianship;
The date of acceptance and, if applicable, date of termination of residency;
Documentation of the resident’s needs required in R9-10-807(B);
Documentation of general consent and informed consent, if applicable;
Except as allowed in R9-10-808(B)(2), documentation of freedom from infectious tuberculosis as required in R9-10-807(A);
A copy of resident’s health care directive, if applicable;
The resident’s signed residency agreement and any amendments;
Resident’s service plan and updates;
Documentation of assisted living services provided to the resident;
A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;
Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes:
The date and time of administration or assistance;
The name, strength, dosage, and route of administration;
The name and signature of the individual administering or providing assistance in the self-administration of medication; and
An unexpected reaction the resident has to the medication;
Documentation of the resident’s refusal of a medication, if applicable;
If applicable, documentation of any actions taken to control the resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;
If applicable, documentation of a determination by a medical practitioner that evacuation from the assisted living facility during an evacuation drill would cause harm to the resident;
Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);
Documentation of the resident’s orientation to exits from the assisted living facility required in R9-10-818(B);
If a resident is receiving behavioral health services other than behavioral care, documentation of the determination in R9-10-813(3);
If a resident is receiving behavioral care, documentation of the determination in R9-10- 812(3);
If applicable, for a resident who is unable to direct self-care, the information required in R9-10-815(F);
Documentation of any significant change in a resident’s behavior, physical, cognitive, or functional condition and the action taken by a manager or caregiver to address the resident’s changing needs;
23. Documentation of the notification required in R9-10-803(G) if the resident is incapable of handling financial affairs; and
If the resident no longer resides and receives assisted living services from the assisted living facility:
A written notice of termination of residency; or
If the resident terminated residency, the date the resident terminated residency.

Top Takeaway:

A manager shall ensure that a resident’s medical record contains:
Documentation of the resident’s needs required in R9-10-807(B);
Resident’s service plan and updates;

The resident medical file must contain the services and needs that are required by the resident. You should include the service plan in this section to ensure you are compliant when the survey team audits the resident file.