Medical Records
1. Confidentiality and security of medical records is assured.
2. Records document status of advanced directive.
3. Records document release of information signed.
4. Patient rights and responsibilities document provided at start of care.
5. RN initial evaluation, plan of care, re-evaluation within 60 days.
6. RN oversight of LPN and CNA documented in record.
7. Evidence of coordination of care with physician.