Nursing home medical records must be well-organized and complete, irrespective of whether they are electronic or paper-based. When the medical charts are in a state of disarray, it could cause major concerns when State inspectors review the nursing home records on behalf of federal inspectors or state-based health departments. Poorly organized records also carry the risk of potential litigation. Attorneys and their paralegals who need to work with medical records, and legal nurse consultants providing medical review services must have a clear understanding of the nature of the nursing home medical record and its components.
The nursing home record of each patient can be voluminous, and if the patient has been a resident for a long time there will be numerous records. Nursing homes may not have a dedicated medical records department or person to organize the records. In such cases, the medical chart which may be very complex, has to be put in order at the law firm or by a legal nurse consultant providing medical records services. Only after proper organization can the medical records be reviewed for legal use in medical malpractice cases or any other medical litigation.
Compared to other healthcare organizations, nursing home records have different medical record sections. So, here’s a look at the categories under which nursing home records are organized properly.
- Administrative Data: This section is usually the first, and contain the following information.
- Admission face sheet
- Leave of absence forms
- Advance directives – which include living will, durable power of attorney, do not intubate, do not hospitalize, do not resuscitate, and so on
- Inventory sheet
- Certification forms
- Hospital transfer forms/li>
- Prior Hospital Records: Nursing homes may maintain only the most recent hospital record information on the medical chart. However, it is important to obtain all prior hospital records as well that may be in filing. Under this category the records included are:
- Emergency room records
- Transfer records presented by the hospital to the nursing home
- Other hospital records
All the records must be chronologically arranged under categories such as progress notes, nursing notes, and so on. Prior records are very important and help determine where and when a certain event occurred and a concern such as a pressure ulcer or skin issue developed.
- Physician Orders: These include
- Pre-printed (monthly) orders
- Telephone orders – Typically, telephone orders are placed after pre-printed orders, unless the telephone orders are grouped by month. If they are grouped by month, place them behind the corresponding printed orders for that particular month. Sometimes, there may be up to four telephone orders on a single page and these may not be arranged date wise. That is why these are usually placed behind the printed orders.
- Miscellaneous Orders: These are placed after telephone orders and include faxed or written correspondence to a pharmacy, dietary changes, therapy orders, and so on.
- Physician Progress Notes
- Initial history and physical
- Progress notes created by the attending physician, physician assistant, nurse practitioner, or extender – in chronological order
- Discharge summary, if the resident has been permanently discharged from the facility
- Consultations: These are sometimes included along with the physician progress notes, or as a separate section after the progress notes. Typical consults include those for podiatry, ophthalmology, dental, surgical, optometry, psychiatry, hospice, wound care and any other consults the physician may consider necessary.
- MDS (Minimum Data Sets) and CAA (Care Area Assessment):
- These are chronologically arranged in this section.
- The CAAs must be immediately after the MDS for which they were produced.
- If the MDSs are stored separately, they may be missing from the record when the chart is reviewed.
- When determining the date of the MDS, use the Assessment Reference Date rather than the signature date. You can find the Assessment Reference date on the top of the page.
- CAAs must be present for the initial, annual, and significant changes MDSs present in the record. CAAs are important because they have a major role to play in the care planning process.
- Care Plans: These may be placed in the MDS section or as a different category. One of the most important nursing home records in terms of litigation, these should be placed in chronological order. These records can be grouped by problems such as risk for fall and injury, or skin breakdown. The care plans determine the care a nursing home resident receives based on data collection for the MDS and assessment decision of the CAA progress.
- At least one care plan must be present for each CAA triggered with care plans for other active diagnosis a resident may have.
- A basic care plan must be included in the record within 24 hours of admission. A comprehensive care plan must be present by day 21 of the stay.
- Many nursing home facilities may draft a new set of care plans on each annual MDS done. Though this is not a federal requirement, it would help if attorneys and medical expert witnesses are aware of this fact when requesting medical records for review.
- Each care plan must include information such an actual potential concern, interventions that should be individualized to the resident, a goal to achieve, and assessment of how the resident is meeting or not meeting that objective.
- The care plans are important when it comes to an actual or potential case of liability when determining a breach in the standard of care.
- Nursing Notes: Nursing assessments/nursing notes should include all admission assessment for each admission to the nursing home. Residents who have been staying at a facility for many years may have a number of admission or re-admission evaluations for each hospitalization. Typically, the nursing assessment comprises a form that is completed when the resident is admitted to the nursing home, and when the resident is re-admitted after a hospital admission.
- All progress notes must be entered with a date, time of entry and a clear signature as well as credentials of the licensed staff member making the entry.
- This section should also have monthly/quarterly summaries that show the status of the resident for the time frame specified. Such summaries are helpful when a medical record review is done and will clear up any gaps between progress notes. Summaries are not federally mandated, rather, it will be based on internal facility policy that governs the same.
- Nursing assessment forms should not be grouped. The initial nursing assessment must be placed first and additional nursing admission forms must be placed chronologically within the nurses’ notes.
- MAR or Medication and Treatment Administration records: Apart from the medication and treatment administration records, this section includes narcotic sheet records, and records relating to monitoring side effects of psychoactive medications. Some nursing homes place both medication and treatment administration records together by month, and some others separate them. Both methods are acceptable, provided the records are organized in month order.
- Resident’s Skin Integrity Status Records: Federal regulation requires that
- All new admissions or readmissions to a nursing home must have a skin risk assessment done at the time of admission, weekly for 4 weeks, monthly for the next 2 months, then quarterly.
- Documentation should be there stating that the resident’s skin was checked weekly for any skin integrity concerns, either in this section or elsewhere in the medical record.
- Pressure ulcer documentation has to be included in this section, and a separate report should be there for each skin concern.
The nursing reports should include the start date of the skin concern; whether it originated before or after admission; type of wound; whether pressure, vascular, surgical; the stage of the wound; measurements in centimeters; course of treatment, and progress towards healing. When such clear documentation is there, it helps determine liability if the case involves development of skin concerns. Ideally, there should be a care plan for each skin issue identified rather than putting them all together on one page. This facilitates medical chart review and is also advantageous for the nursing home facility.
- Other Risk Assessment Records: These assessments include for fall risk assessment, restraint assessment, side rail assessment, and those for pain, incontinence, wandering/elopement, dehydration, urinary tract infection, and choking/aspiration. They are performed on admission or re-admission and quarterly.
- Vital Signs/Weight/Intake and Output Records: A minimum of monthly assessment of vital signs and weight for each month of a resident’s stay is required. Sometimes, more frequent monitoring may be required for these based on the resident’s individual needs, medications, and weight stability. Sometimes, vital signs and weights are documented on separate forms while some facilities group them together. It is best that these records are separated and organized in chronological order.
- Miscellaneous Assessment Records: These include forms that may not fall under any of the above categories. These may be neurological testing, pain assessments, bowel and bladder assessments.
- Therapy Records:
- Physical therapy, occupational therapy, speech therapy, respiratory therapy
- A therapy screen should be there for each discipline when a resident is admitted
- Typically, every quarter, each discipline will screen the resident and the results are entered on a screening sheet that has a space for each discipline.
- The records must be grouped by discipline and placed after the screening sheet. Swallow studies are placed after speech therapy notes.
Bi-weekly progress notes are required for residents receiving therapy, and when a resident’s services are discontinued there should be a discharge summary created.
- Restorative Nursing Records: These shouldn’t be confused with therapy notes because not all medical records will have restorative nursing notes.
- Dietary Records: Contents of these records include initial assessment when the resident is first admitted, which is followed by the narrative dietary notes. Food consumption sheets may be used in some nursing homes, which are placed after the narrative dietary records. Dietary notification slips can be organized in chronological order and placed at the back of the dietary section.
- Activities/Recreational Therapy Records: These include initial activities’ assessment followed by quarterly assessments or progress notes. The narrative section is placed after these records. Individual facilities may have a re-admission assessment or progress note for each time the resident returns from the hospital.
- Lab results/ x-rays, /EKGs: These will be placed in one section, and arranged by type, and then date. It must be ensured that the documents are generated from the facility and not from a prior or interim hospitalization.
- Social Services Records: Here also, there will be an initial assessment record, followed by quarterly updates in the form of progress notes or assessment. Based on facility policy, there may be a re-admission or progress note for each time the resident returns from the hospital. Potential discharge plans and/or burial arrangements may also be included in this section.
- Nursing Assistant Documentation: This may be missing in the set of records released to the attorney because it is usually maintained separately so that nurse assistants can sign during each shift. However, this is an important record when you need to establish that the interventions indicated on the care plan have been implemented. Nurse assistants may also document food and fluid consumption, which is important if there is a weight loss concern.
The above details regarding nursing home records would be helpful for both attorneys handling nursing home related cases and legal nurse consultants doing medical record review for attorneys. Legal nurse consultants will have to review huge amounts of medical records and advise attorneys handling medical litigation. They have to develop medical chronologies and summaries that are easy for the legal team to follow and understand. Whether electronic records or paper-based ones, legal nurse consultants can utilize professional medical review services to lighten their record review work and benefit from accurate and concise medical case chronology and case summary.