OKDHS.org - OAC 340:100-3-40.1 Continuous medical record

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Library: Policy

340:100-3-40.1. Continuous medical record

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Revised 5-15-08

The continuous medical record provides an overview of the medical history and current medical problems of the service recipient.

(1) Form 06HM039E, Continuous Medical Record, is:

(A) initiated by the contract provider;
(B) maintained in the home record per OAC 340:100-3-40; and
(C) required for service recipients who receive:

(i) community residential supports per OAC 340:100-5-22.1; or
(ii) group home services per OAC 340:100-6.

(2) Form 06HM039E includes, but is not limited to:

(A) physician's current diagnosis from Form 06HM005E, Referral Form for Examination and Treatment; and
(B) information regarding:

(i) medical allergies;
(ii) serious diseases and major illnesses;
(iii) surgeries;
(iv) fractures;
(v) sutured lacerations;
(vi) chronic medical conditions, such as seizures or diabetes; and
(vii) reasons for emergency room visits or hospitalizations and diagnosis within the past year.

(3) The health care coordinator:

(A) or back-up as described in OAC 340:100-5-26, is responsible for making accurate entries on Form 06HM039E within 24 hours of occurrence by recording the information identified in OAC 340:100-3-40.1(2) from Form 06HM005E or other medical records; and
(B) obtains the relevant historical information.

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