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Medical Records - Content-N.M. Code R. §

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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