# Minn. R. 4658.0450: CLINICAL RECORD CONTENTS

> Minnesota · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0450

## Section

- **Citation:** Minn. R. 4658.0450
- **Heading:** CLINICAL RECORD CONTENTS
- **Jurisdiction:** Minnesota
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Minnesota Administrative Rules / DEPARTMENT OF HEALTH / Chapter 4658 / Part 4658.0450

## Text

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 .

## Nearby sections

- [Minn. R. 4658.0010 DEFINITIONS](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0010.md)
- [Minn. R. 4658.0015 COMPLIANCE WITH REGULATIONS AND STANDARDS](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0015.md)
- [Minn. R. 4658.0020 LICENSING IN GENERAL](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0020.md)
- [Minn. R. 4658.0025 PROCEDURES FOR LICENSING NURSING HOMES](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0025.md)
- [Minn. R. 4658.0030 CAPACITY PRESCRIBED](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0030.md)
- [Minn. R. 4658.0035 EVALUATION](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0035.md)
- [Minn. R. 4658.0040 VARIANCE AND WAIVER](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0040.md)
- [Minn. R. 4658.0045 PENALTIES FOR LICENSING RULE VIOLATIONS](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0045.md)
- [Minn. R. 4658.0050 LICENSEE](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0050.md)
- [Minn. R. 4658.0055 ADMINISTRATOR](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0055.md)
- [Minn. R. 4658.0060 RESPONSIBILITIES OF ADMINISTRATOR](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0060.md)
- [Minn. R. 4658.0065 RESIDENT SAFETY AND DISASTER PLANNING](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0065.md)
- [Minn. R. 4658.0070 QUALITY ASSESSMENT AND ASSURANCE COMMITTEE](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0070.md)
- [Minn. R. 4658.0075 OUTSIDE RESOURCES](https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0075.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_MN_ADR_4658_0450. Check the current official text before relying on it. Not legal advice.