CALIFORNIA CODE OF REGULATIONS - State of California

Page 637
TITLE 22. DIVISION 5 — LICENSING & CERTIFICATION OF HEALTH FACILITIES § 71549
arrangements with communications media will be made to provide
organized dissemination of information.
(c) The program shall be brought up–to–date, at least annually, and
all personnel shall be instructed in its requirements. There shall be
evidence in the personnel files, e.g., orientation checklist or
elsewhere, indicating that all new employees have been oriented to the
program and procedures within a reasonable time after
commencement of their employment.
(d) The disaster plan shall be rehearsed at least twice a year. There
shall be a written report and evaluation of all drills. The actual
evacuation of patients to safe areas during the drill is optional.
§ 71541. Fire and Internal Disasters.
(a) A written fire and internal disaster program, incorporating
evacuation procedures, shall be developed with the assistance of fire,
safety and other appropriate experts. A copy of the program shall be
available on the premises for review by the Department.
(b) The written program shall include at least the following:
(1) Plans for the assignment of personnel to specific tasks and
responsibilities.
(2) Instructions relating to the use of alarm systems and signals.
(3) Information concerning methods of fire containment.
(4) Systems for notification of appropriate persons.
(5) Information concerning the location of fire fighting equipment.
(6) Specification of evacuation routes and procedures.
(7) Other provisions as the local situation dictates.
(c) Fire and internal disaster drills shall be held at least quarterly,
for each shift of hospital personnel and under varied conditions. The
actual evacuation of patients to safe areas during a drill is optional.
(d) The evacuation plan shall be posted throughout the facility and
shall include at least the following:
(1) Evacuation routes.
(2) Location of fire alarm boxes.
(3) Location of fire extinguishers.
§ 71543. Fire Safety.
All hospitals shall be maintained in conformity with the regulations
adopted by the State Fire Marshal for the prevention of fire and for the
protection of life and property against fire and panic. All hospitals
shall secure and maintain a clearance relative to fire safety from the
State Fire Marshal.
§ 71544. Disruption of Services.
(a) Each hospital shall develop a written plan to be used when a
discontinuance or disruption of services occurs.
(b) The administrator shall be responsible for informing the
Department, via telephone, immediately upon being notified of the
intent of the discontinuance or disruption of services or upon the threat
of a walkout of a substantial number of employees, or earthquake, fire,
power outage or other calamity that causes damage to the facility or
threatens the safety or welfare of patients or clients.
§ 71545. Restraint of Patients.
(a) Restraint shall be used only when alternative methods are not
sufficient to protect the patient or others from injury.
(b) Patients shall be placed in restraint only on the written order of
the physician. This order shall include the reason for restraint and the
type of restraint to be used. In a clear case of emergency, a patient may
be placed in restraint at the discretion of a registered nurse and a verbal
or written order obtained thereafter. If a verbal order is obtained it
shall be recorded in the patient’s medical record and be signed by the
physician on his next visit.
(c) Patients in restraint by seclusion or mechanical means shall be
observed at intervals not greater than 15 minutes.
(d) Restraints shall be easily removable in the event of fire or other
emergency.
§ 71547. Medical Records Service.
(a) The hospital shall maintain a medical record service which shall
be conveniently located and adequate in size and equipment to
facilitate the accurate processing, checking, indexing and filing of all
medical records.
(b) The medical records service shall be under the supervision of
a registered record administrator or accredited records technician.
The registered record administrator or accredited records technician
shall be assisted by such qualified personnel as are necessary for the
conduct of the service.
(c) Policies and procedures shall be established to ensure the
confidentiality of patient health information, in accordance with
applicable laws and regulations.
NOTE: Authority cited: Sections 208(a) and 1275, Health and Safety
Code. Reference: Section 1276, Health and Safety Code.
§ 71549. Medical Record Content.
(a) Each inpatient medical record shall consist of at least the
following:
(1) Identification sheets to include but not be limited to the
following:
(A) Name.
(B) Address on admission.
(C) Identification number (if applicable).
1. Hospital admission number.
2. Social Security number.
3. Medicare number.
4. Medi–Cal number.
(D) Age.
(E) Sex.
(F) Marital status.
(G) Legal status.
(H) Religion.
(I) Date of admission.
(J) Date of discharge.
(K) Name, address and telephone number of person or agency
responsible for patient.
(L) Name of patient’s medical staff member responsible for care.
(M) Initial diagnostic impression.
(N) Discharge or final diagnosis.
(O) Disposition.
(2) Psychiatric history and physical examination.
(3) Legal authorization for admission.
(4) Consultation reports, including neurologic examination.
(5) Order sheet including medication, treatment and diet orders.
(6) Treatment plan.
(7) Progress notes including current or working diagnosis, the
complaints of others regarding the patient, as well as the patient’s
comments.
(8) Nurses’ notes which shall include but not be limited to the
following:
(A) Concise and accurate record of nursing care provided.
(B) Record of pertinent observation of the patient and the response
to treatment.
(C) Name, dosage and time of administration of medications and
treatment. Route of administration and site of injection shall be
recorded, if other than by oral administration.
(D) Record of type of restraint, including time of application and
removal.
(9) Vital sign sheet, including weight record.
(10) Reports of all laboratory tests performed.
(11) Reports of all X–ray examinations performed.
(12) Consent forms, when applicable.
(13) Anesthesia record including preoperative diagnosis, if
anesthesia has been administered.