What must be documented in the resident's medical record when a change is made?

Documentation is crucial in a resident's medical record whenever a change is made, as it ensures transparency, accountability, and continuity of care. Notifying the resident or their representative about changes is essential as it respects the rights of the resident and maintains open communication. This is not only a legal requirement in many jurisdictions but also a best practice to keep residents and their families informed involved in their care.

This documentation fosters trust and ensures that the resident's preferences and concerns are considered. It also provides a record of communication in case there are questions or disputes about the change later. Good documentation practices are foundational in healthcare, as they demonstrate compliance with standards and regulations, ultimately aiming for enhanced patient safety and care quality.

Other aspects mentioned, such as the approval date, reasons for the change, and the resident’s feelings about the change, are important but secondary to the immediate and essential step of ensuring the resident or their representative is informed. Proper notification sets the groundwork for these other elements to be addressed adequately in care planning and review processes.