195 1 2 3 4 5 6 7 8 9 10 11 12 all persons contributing to the resident's habilitation program; "(3) furnishing documentary evidence of the resident's progress and of his response to his habilitation program; "(4) serving as a basis for review, study, and evaluation of the overall programs provided by the facility for its residents; "(5) protecting the legal rights of the residents, facility, and staff; and "(6) providing data for use in research and edu cation. 13 "(b) All information pertinent to the above-stated 14 purposes shall be incorporated in the resident's record, in suf15 ficient detail to enable those persons involved in the resi16 dent's program to provide effective, continuing services. All 17 entries in the resident's record shall be 18 19 22206 21 22 "(1) legible; "(2) dated; and "(3) authenticated by the signature and identification of the individual making the entry. "(c) Symbols and abbreviations may be used in record 23 entries only if they are in a list approved by the facility's 24 chief executive officer and a legend is provided to explain 196 1 them. Diagnoses should be recorded in full and without the 2 3 4 use of symbols or abbreviations. "Subchapter II-Content of Records "SEC. 1179. (a) The following information should be 5 obtained and entered in the resident's record at the time of 6 admission to the facility: "(1) name, date of admission, date of birth, place of birth, citizenship status, marital status, and social se curity number; "(2) father's name and birthplace, mother's maiden name and birthplace, and parents' marital status; "(3) name and address of parents, legal guardian, and/or next of kin; "(4) sex, race, height, weight, color of hair, color of eyes, identifying marks, and recent photograph; "(5) reason for admission or referral problem; "(6) type and legal status of admission; "(7) legal competency status; "(8) language spoken or understood; "(9) sources of support, including social security, veterans' benefits, and insurance; "(10) provisions for clothing and other personal needs; "(11) information relevant to religious affiliation; 1 2 3 4 197 "(12) report(s) of the preadmission evalua tion (s); and "(13) reports of previous histories and evaluations. "(b) Within the period of one month after admission 5 there shall be entered in the resident's record "(1) a report of the review and updating of the preadmission evaluation; "(2) a statement of prognosis that can be used for programing and placement; "(3) a comprehensive evaluation and individual program plan, designed by an interdisciplinary team; and "(4) a diagnosis based on the American Association on Mental Deficiency (AAMD) Manual on Termninology and Classification in Mental Retardation and, where necessary, the Diagnostic and Statistical Manual of Mental Disorders, second edition (DSM-II), published by the American Psychiatric Association. "(c) Records during residence should include "(1) reports of accidents, seizures, illnesses, and treatments thereof, and immunizations; "(2) record of all periods of restraint, with justifica tion and authorization for each; "(3) report of regular, at least annual, review and 1 2 3 4 5 6 198 evaluation of the program, developmental progress, and status of each resident; "(4) observations of the resident's response to his program, recorded with sufficient frequency to enable evaluation of its efficacy; "(5) record of significant behavior incidents; 7 "(6) record of family visits and contacts; 8 "(7) record of attendance and leaves; 9 10 11 12 = 23 13 "(8) correspondence; “(9) periodic updating of the information recorded at the time of admission; and "(10) appropriate authorizations and consents. "(d) At the time of discharge from the facility, a dis14 charge summary shall be prepared that should "(1) include a brief recapitulation of findings, events, and progress during residence, diagnosis, prognosis, and recommendations and arrangements for future programing; "(2) be completed and entered in the resident's record within seven days following discharge; and "(3) with the written consent of the resident or his guardian, be copied and sent to the individual or agency who will be responsible for future programing of the resident. 199 1 2 "(e) In the event of death “(1) a copy of the death certificate should be placed 3 in the resident's record; and 5 7 "(2) when a necropsy is performed, provisional anatomic diagnoses should be recorded within seventytwo hours, where feasible, and the complete protocol should be made part of the record within three months. "Subchapter III-Confidentiality of Records 9 "SEC. 1180. (a) All information contained in a resi10 dent's records, including information contained in an auto11 mated data bank, shall be considered privileged and 12 confidential "(1) the record is the property of the facility, whose responsibility it is to secure the information against loss, defacement, tampering, or use by unauthorized persons; "(2) the record may be removed from the facility's jurisdiction and safekeeping only in accordance with a court order, subpena, or statute; "(3) there shall be written policies governing access to, duplication of, and dissemination of inforination from the record; and "(4) written consent of the resident or his guardian shall be required for the release of information to persons not otherwise authorized to receive it. |