PDFWAC 388-107-0560
Resident records—Clinical records.
(1) The enhanced services facility must:
(a) Maintain clinical records on each resident in accordance with accepted professional standards and practices that are:
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized;
(b) Safeguard clinical record information against alteration, loss, destruction, and unauthorized use; and
(c) Keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is required by:
(i) Transfer to another health care institution;
(ii) Law; or
(iii) The resident.
(2) The enhanced services facility must ensure the clinical record of each resident includes a minimum of the following:
(a) Resident identification and sociological data, including the name and address of the individual or individuals the resident designates as significant;
(b) Medical information;
(c) Physician's orders;
(d) Assessments;
(e) Person-centered service plans;
(f) Services provided;
(g) Progress notes;
(h) Medications administered;
(i) Consents, authorizations, releases;
(j) Allergic responses;
(k) Laboratory, X-ray, and other findings; and
(l) Other records as appropriate.