§ 72547. Content of Health Records.
22 CA ADC § 72547Barclays Official California Code of Regulations
22 CCR § 72547
§ 72547. Content of Health Records.
(4) The orders of a licensed health care practitioner acting within the scope of his or her professional licensure, including drugs, treatment and diet orders, progress notes, signed and dated on each visit. The orders of a licensed health care practitioner acting within the scope of his or her professional licensure shall be correctly recapitulated.
(B) Meaningful and informative nurses' progress notes written by licensed nurses as often as the patient's condition warrants. However, weekly nurses' progress notes shall be written by licensed nurses on each patient and shall be specific to the patient's needs, the patient care plan and the patient's response to care and treatments.
(C) Name, dosage and time of administration of drugs, the route of administration or site of injection, if other than oral. If the scheduled time is indicated on the record, the initial of the person administering the dose shall be recorded, provided that the drug is given within one hour of the scheduled time. If the scheduled time is not recorded, the person administering the dose shall record both initials and the time of administration. Medication and treatment records shall contain the name and professional title of staff signing by initials.
(12) Records of each treatment given by the therapist, weekly progress notes and a record of reports to the licensed health care practitioner acting within the scope of his or her professional licensure after the first two weeks of therapy and at least every 30 days thereafter. Progress notes written by the social service worker if the patient is receiving social services.
Credits
Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
History
1. Amendment of subsections (a)(4) and (a)(12) and Note filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).
This database is current through 4/19/24 Register 2024, No. 16.
Cal. Admin. Code tit. 22, § 72547, 22 CA ADC § 72547
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