WAC 246-337-095   Resident health care records.  The licensee must ensure the RTF meets the following requirements:

     (1) Develop and implement procedures for maintaining current health care records as required by chapter 70.02 RCW and RCW 71.05.390 or by applicable laws.

     (2) Make health care records accessible for review by appropriate direct care staff, the resident and the department in accordance with applicable law.

     (3) Ensure health care records are legibly written or retrievable by electronic means.

     (4) Document medical information on the licensee's standardized forms.

     (5) Record health care information by the health care provider or direct care staff with resident contact to include typed or legible handwriting in blue or black ink, verified by signature or unique identifier, title, date and time.

     (6) Maintain the confidentiality and security of health care records in accordance with applicable law.

     (7) Maintain health care records in chronological order in their entirety or chronological by sections.

     (8) Keep health care records current with all documents filed according to the licensee's written timeline policy.

     (9) Inclusion of the following, at a minimum, in each record:

     (a) Resident's name, age, sex, marital status, date of admission, voluntary or other commitment, name of physician, diagnosis, date of discharge, previous address and phone number, if any;

     (b) Resident's receipt of notification of resident's rights and responsibilities, if applicable;

     (c) Resident's consent for health care provided by the RTF;

     (d) A copy of any authorizations, advance directives, powers of attorney, letters of guardianship, or other similar documentation provided by the resident;

     (e) Original reports, where available or, if not available, durable, legible copies of original reports on all tests, procedures, and examinations performed on the resident;

     (f) Health assessments;

     (g) Health care plan, including the names, relationship to the resident and addresses of those individuals the resident states with whom the RTF may freely communicate regarding the health care of the resident without violating the resident's right to confidentiality or privacy of health care information;

     (h) Dated and signed (or initialed) notes describing health care provided for each contact with the resident pertinent to the resident's health care plan including, but not limited to:

     (i) Physical and psychosocial history;

     (ii) Medication administration, medical/nursing services, and treatment provided, resident's response to treatment and any adverse reactions and resolution of medical issues;

     (iii) Use of restraint or seclusion consistent with WAC 246-337-110;

     (iv) Instructions or teaching provided to resident in connection with his or her health care; and

     (v) Discharge summary, including:

     (A) Concise review of resident's physical and mental history, as applicable;

     (B) Condition upon discharge;

     (C) Recommendations for services, follow-up or continuing care; and

     (D) Date and time of discharge.

     (10) Retaining the health care records at least six years beyond resident's discharge or death date, whichever occurs sooner, and at least six years beyond the age of eighteen.

     (11) Destroying the health care records in accordance with applicable law and in a manner that preserves confidentiality.



[Statutory Authority: Chapter 71.12 RCW. 05-15-157, § 246-337-095, filed 7/20/05, effective 8/20/05.]