Section 1030. Residents' health care records

A. Each resident's health record shall include written documentation of (i) the initial physical examination, (ii) an annual physical examination by or under the direction of a licensed physician including any recommendation for follow-up care, and (iii) documentation of the provision of follow-up medical care recommended by the physician or as indicated by the needs of the resident.

B. Each physical examination report shall include:

1. Information necessary to determine the health and immunization needs of the resident, including:

a. Immunizations administered at the time of the exam;

b. Vision exam;

c. Hearing exam;

d. General physical condition, including documentation of apparent freedom from communicable disease, including tuberculosis;

e. Allergies, chronic conditions, and handicaps, if any;

f. Nutritional requirements, including special diets, if any;

g. Restrictions on physical activities, if any; and

h. Recommendations for further treatment, immunizations, and other examinations indicated.

2. Date of the physical examination; and

3. Signature of a licensed physician, the physician's designee, or an official of a local health department.

C. Each resident's health record shall include:

1. Notations of health and dental complaints and injuries and a summary of the residents symptoms and the treatment given; and

2. A copy of the information required in subsection B of 6VAC35-101-950 (health care procedures).

Historical Notes

Derived from Volume 29, Issue 25, eff. January 1, 2014.

Statutory Authority

§§ 16.1-309.9, 16.1-322.7, and 66-10 of the Code of Virginia.