CALIFORNIA CODE OF REGULATIONS - State of California

§ 77143 CALIFORNIA CODE OF REGULATIONS
Page 664
(N) Discharge or final diagnosis.
(O) Disposition, including aftercare arrangements, plus a copy of
the aftercare plan prepared pursuant to section 1284, Health and
Safety Code, if the patient was placed in the facility under a county
Short–Doyle plan.
(2) Mental status.
(3) Medical history and physical examination.
(4) Dated and signed observations and progress notes recorded as
often as the patient’s condition warrants by the person responsible for
the care of the patient.
(5) Any necessary legal authorization for admission.
(6) Consultation reports.
(7) Medication treatment and diet orders.
(8) Social service evaluation, if applicable.
(9) Psychological evaluations, if applicable.
(10) Dated and signed patient care notes including, but not limited
to, the following:
(A) Concise and accurate records of nursing care provided.
(B) Records of pertinent nursing observations of the patient and the
patient’s response to treatment.
(C) The reasons for the use of and the response of the patient to
PRN medication administered and justification for withholding
scheduled medications.
(D) Record of type of restraint, including time of application and
removal as outlined in section 77103.
(11) Rehabilitation evaluation, if applicable.
(12) Interdisciplinary treatment plan.
(13) Progress notes including the patient’s response to medication
and treatment rendered and observation(s) of patient by all members
of treatment team providing services to the patient.
(14) Medication records including name, dosage and time of
administration of medications and treatments given. The route of
administration and site of injection shall be recorded if other than by
oral administration.
(15) Treatment records including group and individual
psychotherapy, occupational therapy, recreational or other
therapeutic activities provided.
(16) Vital sign sheet.
(17) Consent forms as required, signed by patient or person
responsible for patient.
(18) All dental records, if applicable.
(19) Reports of all laboratory tests ordered.
(20) Reports of all cardiographic or encephalographic tests
performed.
(21) Reports of all X–ray examinations ordered.
(22) All reports of special studies ordered.
(23) Acknowledgement in writing of patient’s rights, as required
in section 77099, signed by patient or person responsible for the
patient.
(24) Denial of patient rights documentation.
(25) A discharge summary prepared by the admitting practitioner
which shall briefly recapitulate the significant findings and events of
the patient’s treatment, his/her condition on discharge and the
recommendation and arrangements for future care.
NOTE: Authority cited: Sections 208(a) and 1275, Health and Safety
Code. Reference: Section 1275.1, Health and Safety Code.
§ 77143. Health Record Availability.
(a) Records shall be kept on all patients admitted or accepted for
treatment. All required records, either as originals or as accurate
reproductions of the contents of such originals, shall be maintained in
a confidential manner, legible and readily accessible upon request of
persons authorized by law to have access to such records including,
but not limited to, persons authorized pursuant to Health and Safety
Code, Section 25250 et seq., those professional persons who are
providing services to the patient and authorized representatives of the
Department and the Department of Mental Health.
(b) The facility shall safeguard the information in the record
against loss, defacement, tampering or use by unauthorized persons.
(c) Patient health records or reproductions thereof, shall be safely
preserved for a minimum of seven years following discharge of the
patient, except that the records of unemancipated minors shall be kept
at least one year after such minor has reached the age of 18 years and,
in any case, not less than seven years.
(d) If a facility ceases operation, the Department shall be informed,
within 48 hours prior to cessation, of the arrangements made for safe
preservation of patient health records.
(e) If ownership of a licensed facility changes, both the previous
licensee and the new licensee shall, prior to the change of ownership,
provide the Department with written documentation that
arrangements have been made for the retention and preservation of all
patient records.
(f) Patient records shall be filed in an easily accessible manner in
the facility or in an approved health record storage facility off the
facility premises.
(g) Patient records shall be completed within 14 days following the
patient’s discharge.
(h) All information and records obtained in the course of providing
services under Division 5 (commencing with Section 5000), Division
6 (commencing with Section 6000), or Division 7 (commencing with
Section 7000) of the Welfare and Institutions Code to either voluntary
or involuntary recipients of services shall be confidential and may be
disclosed only in accordance with Sections 5328 through 5330 of the
Welfare and Institutions Code.
NOTE: Authority cited: Sections 208(a) and 1275, Health and Safety
Code. Reference: Section 1275.1, Health and Safety Code.
§ 77145. Patients’ Monies and Valuables.
(a) No licensee shall use patients’ monies or valuables as its own
or mingle them with its own. Patients’ monies and valuables shall be
separate, intact and free from any liability the licensee incurs in the use
of the licensee’s or the facility’s funds and valuables.
(b) Each licensee shall maintain accurate records of patients’
monies and valuables entrusted to its care. Such records shall include
but not be limited to:
(1) A control account for all recipients and expenditures kept
current with columns for debits, credits and balances.
(2) An account for each patient with supporting vouchers filed in
chronological order and kept current with columns for debits, credits
and balances.
(c) Records of patients’ monies and other valuables entrusted to the
licensee for safe keeping shall include a copy of the receipt furnished
to the patient or to the person responsible for the patient.
(d) Patients’ monies entrusted to the psychiatric health facility shall
be kept in a fireproof safe on the premises of the psychiatric health
facility or deposited in a demand trust account in a local bank
authorized to do business in California and whose deposits are insured
by the Federal Deposit Insurance Corporation. A county psychiatric
health facility may deposit such funds with the county treasurer.
NOTE: Authority cited: Sections 208(a) and 1275, Health and Safety
Code. Reference: Section 1275.1, Health and Safety Code.
Article 5. Physical Plant
§ 77147. Space Conversion.
Spaces approved for specific use at the time of licensure shall not
be converted to other use without the prior approval of the
Department.
NOTE: Authority cited: Sections 208(a) and 1275, Health and Safety
Code. Reference: Section 1275.1, Health and Safety Code.
§ 77151. General Maintenance.
The psychiatric health facility shall be clean, safe and sanitary and
in good repair at all times.
NOTE: Authority cited: Section 208 (a) and 1275, Health and Safety
Code. Reference: Section 1275.1, Health and Safety Code.