Chapter 514 - Nursing Facility Services - DHHR - State of West ...

Name of resident (first, middle, last, and generation if applicable)Date and time of admissionSocial Security identification numberMedicare identification number (where applicable)Medicaid identification number (where applicable) or any other payer identificationnumberMarital statusDate of birthGenderHome addressReligionName, address, and telephone number of referral agency (including institution fromwhich admitted, where applicable)Attending physicianNext of kin or other responsible personAdmitting diagnosisFinal diagnoses (or cause of death)Condition on discharge and disposition (where applicable)Inventory of personal effects.514.11.3 Medical InformationFor each resident, the clinical record must include at a minimum the following information all ofwhich must be signed and dated:Physician's certification reflecting the need for nursing facility services upon admissionto the nursing facility.An overall plan of care based on a comprehensive assessment setting forth goals tobe accomplished, prescribing an integrated program of individually designed activities,therapies and treatments necessary to achieve such goals, and indicating whichprofessional service or individual is responsible for each element of care or serviceprescribed in the plan.Initial medical evaluation including medical history, physical examination, diagnoses,and estimation of restoration potential done on admission.Physician's orders including all medications, treatments, diets, therapies and specialrestorative /medical procedures.Medication and treatment administration records including all medications, treatments,and special procedures performed.Physician's progress reports noted for each visit or consultation describing theresidents’ health status and/or significant changes in resident’s condition.Nursing note documentation must reflect the current conditions as well as changes inconditions of the resident. Monthly documentation which indicates observations,medication changes, progress, regress, any changes in conditions. Physician re-Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 51January 1, 2013DISCLAIMER: This manual does not address all the complexities of Medicaid policies and procedures,and must be supplemented with all State and Federal Laws and Regulations.