Each patient or resident shall have an admission medical history and complete physical examination performed and recorded by a physician within five days prior to or within 72 hours after admission. The medical record shall include: the report of the admission history and physical examination; the admitting diagnosis and report of subsequent physical examinations; a report of a standard Mantoux tuberculin test or, if the Mantoux test is positive or contraindicated, a chest X ray within three months in advance of admission and as indicated thereafter; reports of appropriate laboratory examinations; general medical condition including disabilities and limitations; instructions relative to the patient's or resident's total program of care; written orders for all medications with stop dates, treatments, special diets, and for extent or restriction of activity; physician's orders and progress notes; and condition on discharge or transfer, or cause of death.
Each nursing home patient shall be examined by a physician at least every six months and each boarding care home resident at least annually or more often if indicated by the clinical condition.
A progress note shall be recorded in the patient's or resident's record at the time of each examination.
If orders for the immediate care of a patient or resident are not available at the time of admission, the emergency physician shall write temporary orders which are effective for a maximum of 72 hours.
January 19, 2005
Official Publication of the State of Minnesota
Revisor of Statutes