Standards for Record Keeping 660-05-30-50

(Revised 1/1/08 ML 3118)

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An individualized file shall be maintained for each resident in the home.  At a minimum, the file must contain:

1. The resident's full name and birth date.
2. The name, address, and telephone number of the resident's legal representative when one exists and an emergency contact.
3. Names, addresses, and telephone numbers of persons who can assume responsibility for the resident if the legal representative cannot be reached immediately in an emergency.
4. The daily personal care that is needed and provided to the resident and the name of the individual or individuals who provided the personal care.
5. A single daily entry that itemizes all “routine tasks” completed on a daily basis for a calendar month meets documentation requirements for Adult Family Foster Care unless there was a disruption in the routine care i.e. use of respite care, client hospitalization, etc.  
6. A record of any accident resulting in injury to a resident.