The following minimum information shall be recorded in the resident’s program or medical record upon admission to the community residential home:
  • Name, previous address, and birth date;
  • Name, address, and phone number of legal guardian (if any), person to contact in an emergency; physician, dentist, and case manager; and
  • Special needs, allergies, and current medication. If a resident has an allergy to any substance, a notice shall be placed in a conspicuous place on the resident’s record.
To the extent possible, the following shall also be obtained:
  • The results of assessments conducted within the previous 12 months;
  • All Individuals Service and Support Plans (ISSP) developed within the previous 12 months;
  • Record of prescriptions of illness, accidents, treatments thereof, and immunizations for the previous 12 months;
  • Summary of hospitalizations for the previous 12 months, to include recommendations for follow-up and treatment
  • Any other information relevant to the health of the resident.
CONTINUING RECORD REQUREMENTS
The HRTC shall maintain program and medical records for each resident which also contains the following:
  • All information contained in subparagraph (a) and (b) of this section;
  • A record of the se of the resident’s funds, if such use is supervised by the administrator;
  • Current Individualized Plan (IP) and Individual Service and Support Plans
  • Current photo of resident;
  • General physical characteristics;
  • General description of personality characteristics;
  • Quarterly weight and height measurement of residents under twenty-two years of age;
  • Records of prescriptions ordered and medication administered in the previous twelve (12) months; and
  • When applicable, date and time, and circumstances of resident’s death.
All entries in any resident record shall be dated and authenticated. Acceptable authentication shall be the staff’s written signature, identifiable initials, computer key, or other appropriate technological means
All records specifically required by those standards shall be made available to the Department of Health and Human Services, and Community Mental Health for purposes of enforcing these regulations.

MEDICAL RECORD RETENTION

Medical records are those records pertaining to the health status and related medical services and treatments of the resident. Such records do not include documents involving services and programs.

  • All medical records for adults (persons eighteen (18) years of age or older) shall be retained for no less than ten (10) years after the last date of service or discharge from the HRTC. All medical records for minors shall be retained after the last date of service or discharge from the HRTC for the period of minority plus five (5) years.
CRITERIA:

Males: 12-18
Females: 12-18

Psychological and behavior disorders (suicide attempts, mood/thought disorders, ADHD, Autism and other severe mental disabilities).