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How an Assisted Living Facility Must Manage
A Resident's Medical Records
| (1) Records that pertain to residents must
be treated as confidential and properly safeguarded from
unauthorized use, loss, or destruction.
(2) Resident records must contain: |
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(A) information contained in the facility's
standard and customary admission form;
(B) a record of the resident's assessments;
(C) the resident's service plan;
(D) physician's orders, if any;
(E) any advance directives;
(F) documentation of a health examination by a physician
performed within 30 days before admission or 14 days after
admission, unless a transferring hospital or facility has a
physical examination in the medical record. Christian
Scientists are excluded from this requirement; and
(G) documentation by health care professionals of any
services delivered in accordance with the licensing,
certification, or other regulatory standards applicable to
the health care professional under law. |
| (3) Records must be available to
residents, their legal representatives, and DADS staff. |
*From: Texas Department of Aging and Disability
Services (DADS) Licensing Standards for Assisted Living Facilities
Subchapter A, §92.41
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