(A) Nursing homes shall keep the following records and such other records as the director may require:
(1) An individual medical record shall be maintained for each resident. Such record shall be started immediately upon admission of a resident to the home and shall contain the following:
(a) Admission record. Name, residence, age, sex, race/ethnicity, religion, date of admission, name and address of nearest relative or guardian, admission diagnoses from referral record and name of attending physician and, if applicable, other licensed health professional acting within the applicable scope of practice.
(b) Referral record. All records, reports, and orders which accompany the resident as required by rule 3701-17-10 of the Administrative Code.
(c) Nursing notes and care notes. A note of the condition of the resident on admission and subsequent notes as indicated to describe changes in condition, unusual events or accidents. Other individuals rendering services to the resident may enter notes regarding the services they render.
(d) Medication administration record. A doctor's order sheet upon which orders are recorded and signed by the physician or other licensed health professional acting within the applicable scope of practice, including telephone orders as required by rule 3701-17-13 of the Administrative Code; a nurse's treatment sheet upon which all treatments or medications are recorded as given, showing what was done or given, the date and hour, and signed by the nurse giving the treatment or medication; or other documentation authenticating who gave the medication or treatment.
(e) Resident progress notes. A sheet or sheets upon which the doctor, dentist, advanced practice nurse and other licensed health professionals may enter notes concerning changes in diagnosis or condition of the resident. Resident refusal of treatment and services shall also be documented in the progress notes.
(f) Resident assessment record. All assessments and information required by rule 3701-17-10 of the Administrative Code.
(g) Care plan. The plan of care required by rule 3701-17-14 of the Administrative Code.
(h) Photograph. A photograph is only necessary for residents who have been identified as being a elopement risk. The photograph of the resident shall be updated annually.
(2) The nursing home shall maintain all records required by state and federal laws and regulations, as to the purchase, delivery, dispensing, administering, and disposition of all controlled substances including unused portions.
(3) The nursing home shall maintain a record of all residents admitted to or discharged from the nursing home.
(B) A record shall be kept showing the name and hours of duty of all persons who work in the home. The nursing home shall maintain each employee's current home address in its personnel file.
(C) All records and reports required under rules 3701-17-01 to 3701-17-26 of the Administrative Code shall be prepared, maintained, filed, and transmitted when required, and shall be made available for inspection at all times when requested by the director or his authorized representative. The records may be maintained in electronic format, microfilm, or other method that assures a true and accurate copy of the records are available.
(1) The nursing home shall maintain the records and reports required by paragraph (A)(1) of this rule in the following manner:
(a) The home shall safeguard the records and reports against loss, destruction, or unauthorized use and store them in a manner that protects and ensures confidentiality.
(b) The home shall maintain the records and reports for seven years following the date of the resident's discharge, except if the resident is a minor, the records shall be maintained for three years past the age of majority but not less than seven years.
(c) Upon closure of the home, the operator shall provide and arrange for the retention of records and reports in a secured manner for not less than seven years. The operator shall notify the director of the location where the records will be stored.
(3) Upon the request of the resident, or legal representative, the nursing home shall provide:
(a) Access to medical and financial records and reports pertaining to the resident within twenty-four hours, excluding holidays and weekends; and
(b) Photocopies of any records and reports, or portions thereof, at a cost not to exceed the community standard for photocopying, unless otherwise specified by law, upon two working days advanced notice.
(D) All records and reports required by Chapter 3701-13 of the Administrative Code shall be maintained and made available in accordance with that chapter.
R.C. 119.032 review dates: 10/27/2011 and 12/01/2016
Promulgated Under: 119.03
Statutory Authority: 3721.04
Rule Amplifies: 3721.01, 3721.011, 3721.012, 3721.02, 3721.021, 3721.022, 3721.023, 3721.024, 3721.026, 3721.027, 3721.03, 3721.031, 3721.032, 3721.04, 3721.041, 3721.05, 3721.051, 3721.06, 3721.07, 3721.071, 3721.08, 3721.09, 3721.10, 3721.11, 3721.12, 3721.121, 3721.13, 3721.14, 3721.15, 3721.16, 3721.161, 3721.162, 3721.17, 3721.18, 3721.19, 3721.21, 3721.22, 3721.23, 3721.24, 3721.25, 3721.26, 3721.28, 3721.29, 3721.30, 3721.31, 3721.32, 3721.33
Prior Effective Dates: 5/2/1966, 3/1/71, 3/8/81, 12/21/92, 9/5/97, 10/20/01