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Record of Care, Treatment, and Services (RC) Standards

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Element of Performance

The clinical record contains the following clinical information:
  • The patient’s initial diagnosis, diagnostic impression(s), or condition(s)

  • Any findings of assessments and reassessments

  • Any allergies to food

  • Any allergies to medications

  • Any conclusions or impressions drawn from the patient’s medical history and physical examination

  • Any diagnoses or conditions established during the patient’s course of care, treatment, or services

  • Any consultation reports

  • Any progress notes

  • Any medications ordered or prescribed

  • Any medications administered, including the strength, dose, route, date, and time of administration

  • Any access site for medication, administration devices used, and rate of administration

  • The patient's response to any medication administered

  • Any adverse drug reactions

  • Plans for care and any revisions to the plan for care

  • Orders for diagnostic and therapeutic tests and procedures and their results

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