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Medical Records - Content-N.M. Code R. § 7.9.2.32
Link to the law
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Current as of June 2015
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All long-term care patients’ medical record must contain the following information:
- An admission medical evaluation;
- All physician orders;
- Progress notes;
- Annual physical examinations;
- Nursing services;
- A social history of the resident;
- Documentation of all activities performed;
- Rehabilitative services;
- Dietary assessments;
- Dental services;
- A plan of care; and
- Discharge and transfer information.
Current as of June 2015
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