Minnesota Nursing Home Clinical Record Contents Requirements
Pursuant to Minnesota Administrative Rule 4658.0450 CLINICAL RECORD CONTENTS, Subpart 1. in general. Each resident’s clinical record, including nursing notes, must include:
A. the condition of the resident at the time of admission;
B. temperature, pulse, respiration, and blood pressure, according to part 4658.0520, subpart 2, item I;
C. the resident’s height and weight, according to part 4658.0520, subpart 2, item J;
D. the resident’s general condition, actions, and attitudes;
E. observations, assessments, and interventions provided by all disciplines responsible for care of the resident, with the exception of confidential communications with religious personnel;
F. significant observations on, for example, behavior, orientation, adjustment to the nursing home, judgment, or moods;
G. date, time, quantity of dosage, and method of administration of all medications, and the signature of the nurse or authorized persons who administered the medication;
H. a report of a tuberculin test within the three months prior to admission, as described in part 4658.0810;
I. reports of laboratory examinations;
J. dates and times of all treatments and dressings;
K. dates and times of visits by all licensed health care practitioners;
L. visits to clinics or hospitals;
M. any orders or instructions relative to the comprehensive plan of care;
N. any change in the resident’s sleeping habits or appetite;
O. pertinent factors regarding changes in the resident’s general conditions; and
P. results of the initial comprehensive resident assessment and all subsequent comprehensive assessments as described in part 4658.0400.
Additional Medical Record Content Requirements
Subp. 2. Physician and professional services. The clinical record must contain the recording requirements of parts 4658.0710 to 4658.0725.
Subp. 3. Nursing services. The clinical record must contain the recording requirements of parts 4658.0515 to 4658.0530.
Subp. 4. Dietary and food services. The clinical record must contain the recording requirements of parts 4658.0600 and 4658.0625.
Subp. 5. Resident personal funds account. The clinical record must contain the recording requirements of part 4658.0255.
Subp. 6. Activities. The clinical record must contain the recording requirements of part 4658.0900.
Subp. 7. Social services. The clinical record must contain the recording requirements of parts 4658.1015 and 4658.1020.
Common areas of cases I see include: Falls from Beds, Hoyer Lifts and in the Bathroom; Sexual Abuse; Medication Errors and Others. STOP ELDER ABUSE AND NEGLECT!
For more information about nursing home clinical record requirements or other questions about elder abuse and neglect contact Nursing Home Neglect Attorney Kenneth LaBore for a free consultation at 612-743-9048 or by email at KLaBore@MNnursinghomeneglect.com.