§ 73547. Content of Health Records.
22 CA ADC § 73547Barclays Official California Code of Regulations
22 CCR § 73547
§ 73547. Content of Health Records.
(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 personnel on each patient and shall be specific to the psychological, emotional, social, spiritual, recreational needs and related to the patient care plans.
Progress notes reflecting observations of the patient's response to his environment, physical limitations, independent activities, dependency status, behavioral changes, skin problems, dietary problems and restorative measures to characterize the functional status of progression and/or regression.
(C) Name, dosage and time of administration of drugs, the route of administration if other than oral and site of injection. 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 his initials and the time of administration.
(11) Orders provided by a licensed healthcare practitioner acting within the scope of his or her professional licensure, including drug, treatment and diet orders signed on each visit. Orders provided by the licensed healthcare practitioners acting within the scope of his or her professional licensure recapitulated as appropriate.
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)(5)(A)3., (a)(5)(E) and (a)(11) and new Note filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).
This database is current through 5/10/24 Register 2024, No. 19.
Cal. Admin. Code tit. 22, § 73547, 22 CA ADC § 73547
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