5.11 – Medical Records
Open Door will maintain medical records and documentation for each individual served as outlined in the individual’s plan.
Medical documentation includes, but is not limited to (can be written or through electronic documentation systems):
- Admission records
- Annual History and Physicals
- Medical care plan for all individuals
- Individual health exam/reviews
- Comprehensive medical consults, including referral and coordination with all specialists
- Medication and treatment orders, including necessary labs and tests
- Progress notes
- Hospital visits/Emergency room visits
- Medical assessments
- Incident logs: seizure, falls, bowel tracking, etc…
- Immunization record
- Medication Administration records
For ICF, the medical records should be maintained in the nursing office and in secure electronic documentation systems. Prior medical history documents may be maintained in Corporate storage. For Waiver settings, records are maintained at the service location and in the Corporate office files.
ALL Individuals, guardians, and other treatment professionals may request copy of records through written request and will be issued by written consent.
Last Revised: 8/25/21