0349 Clinical Records – Noncompliance
410 IAC 16.2-5-8.1(a)(1-4)
(a) The facility must maintain clinical records on each resident. These records must
be maintained under the supervision of an employee of the facility designated with
that responsibility. The records must be as follows:
(1) Complete.
(2) Accurately documented.
(3) Readily accessible.
(4) Systematically organized.
0350 Clinical Records – Nonconformance
410 IAC 16.2-5-8.1(b)(1-2)
(b) Clinical records must be retained after discharge:
(1) for a minimum period of one (1) year in the facility and five (5) years total; or
(2) for a minor, until twenty-one (21) years of age.
0351 Clinical Records – Noncompliance
410 IAC 16.2-5-8.1(c)(d)
(c) The facility must safeguard clinical record information against loss, destruction,
or unauthorized use.
(d) The facility must keep confidential all information contained in the resident ‘ s
records, regardless of the form or storage method of the records, and release such
records only as permitted by law.
0352 Clinical Records -Noncompliance
410 IAC 16.2-5-8.1(e)(1-4)
(e) The clinical record must contain the following:
(1) Sufficient information to identify the resident.
(2) A record of the resident’s evaluations.
(3) Services provided.
(4) Progress notes.
0353 Clinical Records – Noncompliance
410 IAC 16.2-5-8.1(f)
(f) The facility shall have a policy that ensures the staff has sufficient information to
meet the residents ‘ needs.
0354 Clinical Records – Noncompliance
410 IAC 16.2-5-8.1(g)(1-7)
(g) A transfer form shall include the following:
(1) Identification data.
(2) Name of the transferring institution.
(3) Name of the receiving institution and date of transfer.
(4) Resident’s personal property when transferred to an acute care facility.
(5) Nurses ‘ notes relating to the resident’s:
(A) functional abilities and physical limitations;
(B) nursing care;
(C) medications;
(D) treatment; and
(E) current diet and condition on transfer.
(6) Diagnosis.
(7) Date of chest x-ray and skin test for tuberculosis.
0355 Clinical Records -Nonconformance
410 IAC 16.2-5-8.1(h)
(h) Current clinical records shall be completed promptly, and those of discharged
residents shall be completed within seventy (70) days of the discharge date.
0356 Clinical Records -Noncompliance
410 IAC16.2-5-8.1(i)(1-8)
(i) A current emergency information file shall be immediately accessible for each
resident, in case of emergency, that contains the following:
(1) The resident ‘ s name, sex, room or apartment number, phone number, age, or date
of birth.
(2) The resident ‘ s hospital preference.
(3) The name and phone number of any legally authorized representative.
(4) The name and phone number of the resident ‘ s physician of record.
Page | 33
(5) The name and telephone number of the family members or other persons to be
contacted in the event of an emergency or death.
(6) Information on any known allergies.
(7) A photograph (for identification of the resident).
(8) Copy of advance directives, if available.
0357 Clinical Records -Noncompliance
410 IAC16.2-5-8.1(j)(1-3)
(j) If a death occurs, information concerning the resident ‘ s death shall include the
following:
(1) Notification of the physician, family, responsible person, and legal representative.
(2) The disposition of the body, personal possessions, and medications.
(3) A complete and accurate notation of the resident ‘ s condition and most recent vital
signs and symptoms preceding death.
0358 Clinical Records -Nonconformance
410 IAC 16.2-5-8.1(k)
(k) The facility shall store inactive clinical records in accordance with applicable
state and federal laws in a safe and accessible manner. The storage facilities shall
provide protection from vermin and unauthorized use.