When a resident moves into your community there are many administrative pieces that are required to be completed by the facility. In addition to your community-specific move-in policies, there are also required documents to be included in the resident file. This is issued by the Maryland Office of Health
Care Quality. Check out the following regulation for what needs to be included on the resident’s file:
.27 Resident Record or Log.
A. The assisted living manager shall ensure that an individual record or log is maintained at the facility for each
resident in a manner that ensures security and confidentiality, and which includes at a minimum:
(1) The documentation required by Regulations .21 and .26 of this chapter;
(2) Medical orders;
(3) Rehabilitation plans, if appropriate;
(4) The service plan;
(5) Care notes as indicated in §D of this regulation; and
(6) The emergency datasheet as described in Regulation .33D of this chapter.
B. Readmission of a Resident.
(1) A resident shall be reassessed by the delegating nurse within 48 hours of readmission to the program if the
following occurs:
(a) Hospitalizations or a 15 day or greater stay in any skilled facility; or
(b) There is a significant change in the resident’s mental or physical status upon return to the program after
an absence from the program.
(2) When the delegating nurse determines in the nurse’s clinical judgment that the resident does not require a
full assessment within 48 hours, the delegating nurse shall:
(a) Document the determination and the reasons for the determination in the resident’s record; and
(b) Ensure that a full assessment of the resident is conducted within 7 calendar days.
C. The assisted living manager shall develop policies and procedures to ensure that all information relating to a
resident’s condition or preferences, including any significant change as defined in Regulation .02B of this chapter, is
documented in the resident’s record and communicated in a timely manner to:
(1) The resident;(2) The resident’s health care representative, if appropriate; and
(3) All appropriate health care professionals and staff who are involved in the development and implementation
of the resident’s service plan.
D. Resident Care Notes.
(1) Appropriate staff shall write care notes for each resident:
(a) On admission and at least weekly;
(b) With any significant changes in the resident’s condition, including when incidents occur and any follow-up action is taken;
(c) When the resident is transferred from the facility to another skilled facility;
(d) On return from medical appointments and when seen in the home by any health care provider;
(e) On return from nonroutine leaves of absence; and
(f) When the resident is discharged permanently from the facility, including the location and manner of
discharge.
(2) Staff shall write care notes that are individualized, legible, chronological, and signed by the writer