The resident medical file

The resident medical file

Every assisted living facility in the state of Hawaii is required to keep a medical file for each resident under their care. 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 the Office of Healthcare Assurance for what is to be included in the healthcare record:

  • 11-90-9 Record and reports system.

(a) The facility shall establish policies and procedures to maintain a system of records and reports which shall include the following:

(1) Copy of a current physician or primary care provider’s report of resident’s physical examination which includes tuberculosis clearance and verification that the resident is free from other infectious or contagious diseases;

(2) Service plan;

(3) Contracts or other documents which set forth details of services to be delivered, charges, and other conditions agreed to between the resident and the facility; and

(4) Incident reports of any bodily injury or other unusual circumstances affecting a resident which occurs within the facility, on the premises, or elsewhere, shall be retained by the facility under separate cover, and be available to authorized personnel and the department. The resident’s physician or primary care provider shall be called immediately if medical care is necessary or indicated.

(b) The facility records and reports shall be available for review at any time by authorized personnel and the department.