CMS Manual System - Louisiana Department of Health and Hospitals

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F514
§483.75(l) Clinical Records
(1) The facility must maintain clinical records on each resident in accordance with
accepted professional standards and practices that are--
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized.
Intent §483.75(l)(1)
To assure that the facility maintains accurate, complete and organized clinical
information about each resident that is readily accessible for resident care.
Interpretive Guidelines §483.75(l)(1)
A complete clinical record contains an accurate and functional representation of the
actual experience of the individual in the facility. It must contain enough information to
show that the facility knows the status of the individual, has adequate plans of care, and
provides sufficient evidence of the effects of the care provided. Documentation should
provide a picture of the resident‘s progress, including response to treatment, change in
condition, and changes in treatment.
The facility determines how frequently documentation of an individual‘s progress takes
place apart from the annual comprehensive assessment, periodic reassessments when a
significant change in status occurs, and quarterly monitoring assessments. Good practice
indicates that for functional and behavioral objectives, the clinical record should
document change toward achieving care plan goals. Thus, while there is no ―right‖
frequency or format for ―reporting‖ progress, there is a unique reporting schedule to chart
each resident‘s progress in maintaining or improving functional abilities and mental and
psychosocial status. Be more concerned with whether the staff has sufficient progress
information to work with the resident and less with how often that information is
gathered.
In cases in which facilities have created the option for an individual‘s record to be
maintained by computer, rather than hard copy, electronic signatures are acceptable. In
cases when such attestation is done on computer records, safeguards to prevent
unauthorized access, and reconstruction of information must be in place. The following
guideline is an example of how such a system may be set up: