What must be included in the documentation of a resident’s transfer or discharge?

The inclusion of the date, reason, and a physician's note if applicable in the documentation of a resident's transfer or discharge is critical because it ensures that all necessary legal and clinical information is accurately recorded. Documenting the date provides a clear timeline of when the transfer or discharge occurred, which is essential for continuity of care and for any future healthcare encounters. The reason for the transfer or discharge helps to understand the context of the resident's care, whether it is due to improved health, a need for different levels of care, or other factors. Incorporating a physician's note enhances the documentation, as it confirms that the medical professional has assessed the resident and has recommended the transfer or discharge, ensuring that care decisions are made with professional oversight. These elements collectively support compliance with regulations and promote the safety and well-being of the resident throughout the transition.

Incorporating the previous medical treatments, family member's contact information, or medication history may be useful in some contexts but do not directly address the most critical aspects required for lawful and effective documentation of a transfer or discharge.