Health Care Services - 10-144-118 Me. Code R. § 10

Prior to a patient’s admission, a physician must gather the patient’s medical history, current medical findings and certify that the admission is necessary.  After admission, the physician must establish a plan of care and carry out a complete physical examination of the patient.  The plan of care needs to be reviewed and reordered by the physician ever 90 days.  Individual medication administration records must be maintained for each client, which includes the name of the drug, dosage, time given and the initials of the administering individual with the full name of the individual written somewhere on the record.  Entries of the medication record must be made whenever the medications are started, given, discontinued or refused, or when a medication error is made.  Additionally, any oral order by a physician for medication must be recorded in the client’s record immediately by the person taking the order, including a signature by both the recorder and the physician.  Finally, any dental services provided must be recorded in the patient’s record, including the findings of the dental examination, a summary of the services performed, any recommendations for treatment, return date, the dentist’s signature and date of entry.