CLINICAL RECORD CONTENTS

Subpart 1. In general. Each resident's clinical record, including nursing notes, must include: A. the condition of the resident at the time of admission; B. temperature, pulse, respiration, and blood pressure, according to part 4658.0520 , subpart 2, item I; C. the resident's height and weight, according to part 4658.0520 , subpart 2, item J; D. the resident's general condition, actions, and attitudes; E. observations, assessments, and interventions provided by all disciplines responsible for care of the resident, with the exception of confidential communications with religious personnel; F. significant observations on, for example, behavior, orientation, adjustment to the nursing home, judgment, or moods; G. date, time, quantity of dosage, and method of administration of all medications, and the signature of the nurse or authorized persons who administered the medication; H. reports of laboratory examinations; I. dates and times of all treatments and dressings; J. dates and times of visits by all licensed health care practitioners; K. visits to clinics or hospitals; L. any orders or instructions relative to the comprehensive plan of care; M. any change in the resident's sleeping habits or appetite; N. pertinent factors regarding changes in the resident's general conditions; and O. results of the initial comprehensive resident assessment and all subsequent comprehensive assessments as described in part 4658.0400 . Subp. 2. Physician and professional services. The clinical record must contain the recording requirements of parts 4658.0710 to 4658.0725 . Subp. 3. Nursing services. The clinical record must contain the recording requirements of parts 4658.0520 to 4658.0530 . Subp. 4. Dietary and food services. The clinical record must contain the recording requirements of parts 4658.0600 and 4658.0625 . Subp. 5. Resident personal funds account. The clinical record must contain the recording requirements of part 4658.0255 . Subp. 6. Activities

0725 . Subp. 3. Nursing services. The clinical record must contain the recording requirements of parts 4658.0520 to 4658.0530 . Subp. 4. Dietary and food services. The clinical record must contain the recording requirements of parts 4658.0600 and 4658.0625 . Subp. 5. Resident personal funds account. The clinical record must contain the recording requirements of part 4658.0255 . Subp. 6. Activities. The clinical record must contain the recording requirements of part 4658.0900 . Subp. 7. Social services. The clinical record must contain the recording requirements of parts 4658.0450 and 4658.1005 .