§ 2600.252. Content of resident records.
Each residents record must include the following information:
(1) Name, gender, admission date, birth date and Social Security number.
(2) Race, height, weight, color of hair, color of eyes, religious affiliation, if any, and identifying marks.
(3) A photograph of the resident that is no more than 2 years old.
(4) Language or means of communication spoken or used by the resident.
(5) The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
(6) The name, address and telephone number of the residents physician or source of health care.
(7) The current and previous 2 years physicians examination reports, including copies of the medical evaluation forms.
(8) A list of prescribed medications, OTC medications and CAM.
(9) Dietary restrictions.
(10) A record of incident reports for the individual resident.
(11) A list of allergies.
(12) The documentation of health care services and orders, including orders for the services of visiting nurse or home health agencies.
(13) The preadmission screening, initial intake assessment and the most current version of the annual assessment.
(14) A support plan.
(15) Applicable court order, if any.
(16) The residents medical insurance information.
(17) The date of entrance into the home, relocations and discharges, including the transfer of the resident to other homes owned by the same legal entity.
(18) An inventory of the residents personal property as voluntarily declared by the resident upon admission and voluntarily updated.
(19) An inventory of the residents property entrusted to the administrator for safekeeping.
(20) The financial records of residents receiving assistance with financial management.
(21) The reason for termination of services or transfer of the resident, the date of transfer and the destination.
(22) Copies of transfer and discharge summaries from hospitals, if available.
(23) If the resident dies in the home, a copy of the official death certificate.
(24) Signed notification of rights, grievance procedures and applicable consent to treatment protections specified in § 2600.41 (relating to notification of rights and complaint procedures).
(25) A copy of the resident-home contract.
(26) A termination notice, if any.
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