Edition 15: April 4, 2025

Here are a few things to know about observation notes.



1. A note must be documented on each resident at least monthly.
2. If there is a significant change in a resident’s medical condition or the occurrence of a serious incident, you must document daily until the condition is stabilized and/or the incident is resolved.
3. Notes should state more than “The resident is ok” or “Mr. Greene had a great day.” The notes should be detailed. Include information about any changes in their behaviors, health, eating habits, incidents/accidents, physical/mental state, activities, or improvements.

Have you verified your residents’ Code Status?

• Code Status refers to the level of medical interventions a person wishes to have started if their heart or breathing stops.
• Documenting the resident’s Code Status is critical in ensuring the resident’s request and Resident Rights' are being met. The Facility MUST accurately and consistently document the resident’s Code Status throughout the resident’s medical record. Additionally, the Facility MUST have systems in place, which are supported by policy and procedure, to document a resident’s choice regarding Code Status. Physician orders to support these choices should also be obtained.
• In order to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident, Facilities must ensure that properly trained personnel (and certified in CPR for Healthcare Providers) are available immediately (24-hour per day) to provide basic life support, including cardiopulmonary resuscitation (CPR), to residents requiring emergency care prior to the arrival of emergency medical personnel,
• The American Heart Association (AHA) publishes guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). The AHA urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer.

CFR §483.24(a)(3) Quality of Life – Cardio-Pulmonary Resuscitation (CPR)

Regulations require fire drills to be completed quarterly for each shift. SC Fire Codes also require that fire drills be held at unexpected times and under varying conditions. Fire Drills conducted during a shift change will only be counted for one shift, not both. The time to complete the fire drills must be documented. Remember, in CRCF’s evacuation to the outside of the building is required for all fire drills. However, there is no time limit to complete the evacuation, the goal is a safe and orderly evacuation

(Regulation 61-84.1504, 61-17.1604, SCFC 405)

Healthcare Quality

S.C. Department of Public Health

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