How to read nursing home records

How to read nursing home records

In any nursing home abuse lawsuit, the resident’s nursing home records hold the clues that unlock the case. From medication administration records to the admission package, nursing home records are the keystone for understanding what went wrong after an injury. In today’s episode, nursing home abuse lawyers Rob Schenk and Schenk Firm talk what families should know about nursing home records with guest Tory Palivoda, RN and legal nurse consultant.

Schenk: Hello and welcome back to the Nursing Home Abuse Podcast. This is Episode 114 – 114, man.

Smith: Mm-hmm.

Schenk: Like remember when we first started doing this?

Smith: I do.

Schenk: Hasn’t gotten any easier.

Smith: It has not gotten – no, it’s gotten more efficient. It’s gotten better with the guest.

Schenk: Yeah, that’s true. We learned to batch all the episodes together and it gets published in particular intervals, so this is – as we’re filming this, this episode won’t come out for a long time, but when it does, it’ll be April 15th, Tax Day. But what – this will be the last thing I talk about – I feel like Daniela is, every other episode, we talk about Daniela, who is, as of today’s date, my wife in the eyes of the community, but not in the eyes of the government. I don’t know how you say that.

Smith: Okay.

Schenk: So Wednesday, April 17th, is the date that we actually go to the courthouse and become civilly married in Atlanta, Georgia.

Smith: Excellent.

Schenk: That’s where our plan is.

Smith: Yeah.

Schenk: So again, over the span of us doing this podcast, I just met her, dated her, became engaged and now have become – married in church, and now married.

Smith: And you know what’s significant is this is podcast 114, and half of 114 is 57, and that the date that you’re actually getting married is 4/17, and 4 + 1 is 5, 57. Or you can keep adding and it equals 12, which is the same thing that 57 equals, which is half of…

Schenk: Six.

Smith: Which is half of 114.

Schenk: That’s right.

Smith: Yeah.

Schenk: I didn’t see where you’re going there. But I can tell you this – that was gibberish and for some people, medical records and nursing home records can be gibberish. And so that’s the point of today’s episode is to understand how to read and interpret and to really comprehend and understand nursing home records for if your loved one is in a nursing home.

And we’re not doing that alone. We have a guest with us today. Her name is Tory Palivoda. She’s a nurse, and Will, can you tell us a little bit more about her?

Smith: Yeah, Nurse Palivoda is a registered nurse who’s dedicated most of her 30-year career to working in nursing homes in Arkansas, Ohio and Florida. She’s held many different roles, including unit charge nurse, staff development, quality assurance, risk manager and director of nursing.

Currently, she is the clinical educator of a skilled rehab facility in Florida and she has her own legal nurse consulting company, Palivoda Legal Nurse Consultants. She is currently completing her wound care certification as well. As a certified legal nurse consultant, she’s able to assist attorneys by analyzing the medical record and interpreting the information and its relevance to the case. Medical records are saturated with tedious medical vocabulary, and a nurse is a perfect person to interrupt them for an attorney or a jury – I’m sorry, to interpret them for an attorney or a jury, and that’s what she does as a certified legal nurse consultant. So we’re very happy to have somebody with her expertise today on the show.

Nurse Palivoda, welcome to the show. How are you?

Tory: Thank you, I’m great. Thank you for having me.

Smith: So I want to kind of jump right into this. One of the things that you do, and I know that you’re getting your certification for wound care, that you’ve been everything from a charge nurse to a director of nursing, so you have a huge background of knowledge, but one of the things that you help attorneys do is understand medical records.

Tory: Yes.

Smith: Are nursing home records the same as medical records?

Are nursing home records the same as medical records?

Tory: Yes, they are. Every resident that enters a nursing home has a medical record started pretty much from the minute they arrive. Sometimes it’s even started before they arrive. The electronic health record, we frequently get records from the hospital sent electronically before the patient even arrives.

Smith: Yeah. What are in these nursing home records?

Tory: Well every nursing home record is really set up very similar. So if I were reviewing a nursing home record or a family was, I would expect to see probably about 10 or 11 different areas. So I’ll just quickly go over those.

What are the different categories of nursing home records?

Smith: Yeah, please.

Tory: And if you have questions, let me know. But the first section, I think would be an administrative section, kind of face sheet, advanced directive. Next I would see hospital records if they came from the hospital, all the hospital records with the HMPs, so we would get to know what is going on with that resident before they get to us.

Then we’d normally see physician’s orders, physician’s progress notes. The progress notes are done as the physician comes to the nursing home and sees that they patient. They do a progress note every time they visit.

Next we might see consultation reports from like from podiatry, dental, psychiatry, and then we would go right into the assessment, which is a big part of the chart. That’s where we see risk assessment, such as maybe pain assessment, a fall assessment, skin, dehydration – there are lots of different assessments that are done on admission, and then on a scheduled basis while they’re there, whether it’s quarterly or weekly.

The next part is really probably the most important piece of the medical records, and that’s the care plan. Care plan is really the road map to the care that’s delivered to that resident. These care plans are developed from many, many different assessments that are done. It’s done with their diagnosis, with their medication, so all of this is developed into a care plan and there are three parts to that – usually a problem statement, a goal for that problem statement and then interventions.

So for example, if somebody came in and let’s say they had no skin issues – their skin was good – but they’re diabetic. They have fragile skin and they have limited mobility. They may be at risk for skin problems, so we would institute a care plan for a potential for risk for skin. So these care plans are kind of an ever-growing, breathing, changing part of the medical record.

Smith: So who participates in that care plan?

Who participates in the care plan of a nursing home resident?

Tory: All the disciplines, and we call them disciplines in the nursing home – that would include nursing, dietary, activities, social services, the physician, the resident, the family. Those are kind of the key players that participate in development of the care plan.

Smith: Got you.

Tory: And we do include that resident in it.

Schenk: Got you. And this is really great, so keep going. What’s after the care plan? What else is in those records?

What is a Medication Administration Record?

Tory: A couple more pieces. So the next part I would expect to see if I was doing a chart with you would be what we call MAR, which is the medication administration record. This is where the nurse documents all the medications that he or she has given the resident, and it’s usually done on a monthly basis.

And then you’re going to see nurse notes and other discipline’s nurse notes, social services, activities, dietary. And these notes can be daily, it can be weekly, it just kind of depends on the individual and what they’re there for. You’re going to see skin assessments, normally a weekly skin assessment, and then you’re going to have therapy notes and you’re going to have lab X-rays. You have a section for labs and that X-ray.

And then there’s also a section for the nursing assistant documentation. So in the facility, there’s nursing assistants that do the bathing and the toileting and those types of things. So they also do documentations.

So that’s really all of the pieces, the main pieces that you would see in a medical record, that I would expect to see. So if I didn’t see something, I’d think something’s missing.

Smith: And is there a huge difference between, and I think a lot of times nomenclatures are just different depending on where you go, is there a huge difference between the TAR and the MAR?

What is a Treatment Administration Record?

Tory: Yes. The MAR is medications, like pills and that type of thing, where the TAR is treatments, that would be like a wound dressing, a lab, a specialty mattress. Those types of things would be documented on a TAR.

Schenk: And that’s actually, Will brings up a good point. Where would you say the ADL documentation would be found? Would that be in the NA docs in terms of the implementation of the ADLs?

Tory: Yes. Yes, the ADL documentation would be done by the nursing assistants. That’s usually a separate form or a separate part of this computerized program.

Schenk: And you mentioned in a few of these different categories of nursing home records that they’re updated sometimes daily, sometimes weekly, sometimes whenever with regard to the progress notes, whenever the physician is there. How often are nursing home records, just in general, updated? Does it depend?

How often is a nursing home record updated?

Tory: Yes, well if they’re a skilled patient, which means they’re just recently discharged from a hospital, then you would expect they have to have daily documentation by the nursing. That’s a Medicare requirement. They would need to have some type of a daily assessment done, minimal. If they’re a long-term care resident and they’ve been there for years or months, they may only have a weekly nurse note just summarizing the week. But for the most part, you know, there are several entries in a week’s time for the long-term care because the dietician might enter something, the doctor might enter something, the nurse is going to write an order, so it’s a pretty fluid document as far as entries. But a skilled patient, a short-term from the hospital, you would expect to see a lot more documentation, just because there’s still a lot going on with that patient they should be assessing to make sure there’s no change in their condition.

Schenk: Right. So you’re obviously a veteran at this, but if somebody picked up one of these, like let’s say for example, the nurse assistant’s documents that show the ADL implementation, so would you say that that document is more geared towards the documentation of it in terms of it’s easier to put down what you did versus actually read and understand what happened? So I guess that’s a really dumb way of asking is it easy to read?

Are nursing home records easy to read?

Tory: Yeah. The nursing assistant documentation is pretty much going to be checkboxes for the most part of what they did. Like for example, if they’re transferring somebody, there’s going to be a section on how did that patient transfer? So the nursing assistant will probably have five different choices. It may be independent – were they independent with the transfer? Were they supervision? Were they limited assistance, meaning they needed some help but they did some of it? Was it extensive, meaning you did weight-bearing support, you had to help lift them? Or were they maybe 100 percent dependent for that? So you may have transferring bed mobility, eating, toileting, bathing, all of those types of ADLs that the nursing assistant is going to document on every day. And it really can vary from shift to shift because somebody can be pretty independent during the day but at night, they need a lot more care because it’s nighttime and they’ve been in bed, so they may need more assistance. So it really varies sometimes during the day also.

Schenk: I see. And you mentioned one of the categories of these nursing home records would be assessments. Do you include the MDS in that category?

What is an MDS?

Tory: Yes. Yeah, the MDS is a whole separate section that we are required to do if it’s a Medicare/Medicaid building, so we do an MDS depending on if they’re managed care or if they’re just a straight Medicare. If they’re a straight Medicare patient, then they’re going to have a complete Medicare assessment done five days after they’ve been here 14 days, 30 days, and then ongoing. Sometimes there’s even more in between them. If therapy changes, there’ll be an extra assessment. If they have a condition change, they’re going to do an extra assessment. And these are submitted to CMS, which is Centers for Medicare/Medicaid Services for reimbursement purposes. So we also derive the care plan from that information too.

Schenk: I see. So let’s talk about what person, obviously if the individual resident would like to see it, if they have the capacity to request them, to look at them, I’m sure that’s okay, but what’s your understanding of who is allowed to access the nursing home records and under what circumstances?

Who has access to nursing home records?

Tory: Okay. Well a reason why – there are a couple of reasons why a family or a patient might request to see their medical records. One is sometimes families just want to keep a very detailed medical record on Mom or Dad’s medical history, what labs they’ve had, what doctors said, everything that occurred. Sometimes it’s just information that they want.

Other times, the families or the patients have been unhappy with something that has occurred at the facility. They had a fall that resulted in a hip fracture. They have a skin area they didn’t have when they came in. Sometimes they’re looking for specific issues in that record, which again sometimes leads to that visit with the attorney. If they feel like they’ve been done wrong by the nursing home, they’ll request that record so they can try to look through it and see i they find anything themselves, or again, take it to an attorney and see if they might have an issue.

Schenk: That’s an excellent point. And to that point, let’s give you a hypothetical then where a family of a loved one that’s in a nursing home, perhaps they were told that they were drowsy and fell. And so the family says, “Well give me the entire file,” and they get the entire file. What are some of the more important categories of nursing home records that you would look at? Like what can a family member – what should they go to first whenever they’re trying to evaluate what’s going on with their loved one?

What categories of nursing home records are more important?

Tory: A couple areas. One would be I would definitely look at the nurse note, the nursing assessment of the nurse note from the timeframe that they’re looking at, like a couple days before Mom started getting drowsy, and read through the nurse notes. See if there are any, if the nurses documented that the patient was different, something was going on. And if they did document it, patients seem more lethargic than usual, did they notify the physician? Did they call the doctor and let them know of this change of condition? That would be one key factor.

Second thing I would look at would definitely be the care plan. Did they care plan that there was a change? Did they document that there was a change in her being more sleepy, I think is what you said. So I would look at the care plan. I would also look at the physician orders. Did she have any medication changes a day or two prior to this? Did they start her on some type of a medication that possible has a side effect of sleepiness? If they did, then that would be something that they needed to address, that the nurses in the nursing home should know that if they started him on, let’s say narcotics for pain, that’s going to make them more sleepy, so they would need to address it.

Schenk: Will has often talked about his background in working in a nursing home and he talks about his understanding that some people, not him, but some people in his experience, would have what’s called charting parties.

What is a charting party in a nursing home?

Smith: Oh, absolutely.

Schenk: Can you describe what a charting party is and how that affects the accuracy of a nursing home record?

Tory: Well I guess if I’m thinking of what a charting party – I’ve never really used that phrase – that’s not something I’m real familiar, but I’d imagine it’s like, “Let’s catch up on charting” kind of is what I’m guessing.

Smith: Yeah. I think it happens on the ADLs the most.

Tory: Okay.

Smith: And maybe some nurses notes.

What is charting by exception?

Tory: Yeah, I mean that’s just not a good practice at all. I mean you can’t remember what you did three days ago let alone a week ago if you’re trying to back-chart on something. So it’s crucial that the facilities have some type of a tracking to make sure that everything is done on a daily basis when it’s supposed to be done. So I think that’s important because if they’re trying to backtrack and chart, they’re just going to chart what somebody before them charted. I mean we call it parrot charting or copy charting, something like that.

Smith: Or charting by exception, yeah.

Tory: Yeah. Yeah, so it is crucial, and again, we’ve said this many times, nurses have heard this many times, if it wasn’t charted, it wasn’t documented, it wasn’t done. So it’s important that you document the things that you do in a timely basis. It’s okay if you forget to document and you come back the next day – you just do a late entry. It’s understandable that sometimes late entries happen, but you did go back and document something that happened the prior day. But to just wait and do it all at one time would definitely be an issue. You’re not going to have accurate information.

Smith: Well with that in mind too, that is sometimes an issue that we face now. Another issue that we face, and I’m curious if you’ve experienced this a lot, is just not adequate records at all. I’ve had places – I’ve had some places that they’re state of the art, they record everything, and then I’ve had some rinky-dink little nursing home and it’s like you guys don’t chart anything. Do you see that where they’re missing charts or missing pages?

How can you determine if nursing home records are missing?

Tory: Yes, definitely. And a lot of times, I think the facilities that struggle with having appropriate documentation and complete medical records really are sometimes facilities that have a high turnover of staff. If you have consistent staff and the same DON and the same nurses over and over, most of the time you have pretty good medical record outcome. But it’s when you have different nurses in every day or you have agency or you just have new staff starting all the time, that’s when I think the medical record gets a little bit out of sort and people don’t realize that they’re missing things until you’re too late.

But yes, I definitely do see charts that are completely missing things, like recently I reviewed chart that had no care plans, I mean absolutely no care plans. I’m thinking, “How can that be?” It’s very unusual to not see some care plan. Maybe they’re not accurate, but to not have any care plans was definitely an area of issue with that case.

Schenk: Well speaking of missing documents, when a nursing home resident is sent out to the hospital for whatever reason and they come back to the nursing home, does the nursing home have access to those records and do those records become a part of the nursing home file?

Do other types of medical records become part of the nursing home file?

Tory: The hospital records?

Schenk: Correct.

Smith: Yes ma’am.

Tory: Yeah. So when somebody is being sent to the hospital, like say we’re sending somebody to the hospital, we always try to send a few things. It just depends on how urgent. If it’s a 911, we have to get the patient out right away, we always make sure we send a face sheet that has the demographics and that, diagnosis and a medication list. Those would be the two minimal that we would send with a patient. And then we would get with the ER later and send them more things. But if we have time and it’s not an emergency transfer, we’re going to make sure we send as much as we can with that patient to the hospital so that the continual care is well for that patient. We may send a history, physical, consultation, labs, recent labs, things like that. So as far as what we send to the hospital, we try and send as much as we can to help them to be able to take care of our patient when we go.

Now when the patient comes back from the hospital, we frequently get a lot of medical records from the hospital. Now those medical records, those copies that we get from the hospital, do become part of our medical record for the nursing home.

Schenk: I got you. And that leads me to the next question then. I’m sure that can be very voluminous.

Tory: Yeah.

Schenk: So in your experience, are most nursing home records, are they accessible – first of all, it’s a two-part question then – so when the records are being generated, so for example, we use the nursing assistant documents, are those being punched in electronically, and if so, are they coming out electronically? And if they are punched in electronically, is there ever a time where they come out paper-wise? And I ask that for the family members that are thinking of getting some nursing home records, is it going to be a box of paper or is it going to be like a thumb drive?

What format are nursing home records in?

Tory: Actually they can get it on a disc if they would like or they can have the paper copy. Either way, but definitely, the nursing assistant documentation would come out on a paper form and it would be probably for the whole month, like it would tell you what that nursing assistant answered for that month for that question. Usually everything’s kind of in a month. But when they do ask for their records, they, like I said, there’s a timeframe of what we have in order to prepare that record for them, so depending on if they want a digital copy or paper copy, we would produce that.

Schenk: For a family member that is not familiar with medical records, nursing home records, are there any tools that you would recommend to them? For example, if they have the records in front of them, should they have their computer open to like dictionary.com or whatever a medical dictionary so they can look up short references and things like that? Do you have any tools or things you can suggest?

Tory: I don’t know of a specific tool for them to be truthful, but when you request the medical record, probably the key is to request all the medical records if you can, because if you just say, “I only want the nurse notes” or “I only want…” you’re only going to get what you ask for. So you can request the whole thing, which sometimes, like I said, can be a huge amount of paper, and sometimes it can be a little costly depending on how much they charge per page, or you can just specifically start out by asking, “Hey, I want the nurse notes first and MARs and the orders,” and something like that. And then if you don’t have everything you need, then you can say, “Okay, the therapy notes and I’d like…” You might do it that way to just get what you need to start out with and if you’re not getting the answers, then ask for more.

Schenk: That makes sense. And in terms of the layout of the documents, so for example, the MARs, those notes or reports, are these easy to digest? Like do you need to have a medical degree to look at them?

Can a regular person read nursing home records?

Tory: I don’t think so. I mean it’s pretty much – an MAR is going to have on the left side, it’s going to have the medication, like, you know, Coumadin, and then you’re going to have 30 boxes, 31 boxes after that, and then the nurse is going to have her initial there if that medication was administered. If it’s not, then there would be a notation as to why they didn’t give it. So I think if they’re looking at an MAR, they’d be able to figure out like, “Wait a minute, Mom’s supposed to be on this medicine tonight. I don’t see it anywhere on this list.” So they’ll probably be able to figure that out.

Schenk: Right. I know from my experience reading over notes is I generally – I cannot remember for the life of me what the website is, but I’ll have to Google common acronyms, if that’s the right word, like D/C for discharge or complaints – what am I looking for?

Tory: CO for complaints.

Schenk: CO, yeah, all these types of things that can be confusing if you’re not used to seeing them, so I myself, that’s a tip, would encourage people just to have the Internet open as you’re reading through and you can go, “What is XYZ mean in medical terms?” and generally that can point you in the right direction.

Tory: Absolutely. I agree too. As nurses, we use acronyms for everything, and there are sometimes, even when I look at a chart, I’m like, “What does that mean?” And I’m doing the same thing myself. But yeah.

Schenk: Yeah. And tell us a little bit about your consulting, your consulting practice, who you work with mostly? Do you do mostly medical malpractice or do you have a particular type of case that you look at?

Tory: Well mainly I’ve done both – defense part of medical malpractice, like the nursing home, we read charts for the nursing home attorney that says, “Hey, look at these charts and tell me what areas you’re finding are problematic for us,” that type of thing. So I’ve done that but I’ve also done the plaintiff side, which is the family member that says, “Hey, something’s gone bad with Mom. I know that,” and then I help to look at those charts to see if the nursing homes followed the standard of care. Did they follow the normal protocols for different things, whether it’s fall or skin or lab results or change of conditions? So I’ve really done both sides at this point.

I’ve done a lot, like I said, of the behind the scenes chart readings for these attorneys to help them understand the charts and what you were talking about, what does this acronym mean? What’s this thing? What do they need to be aware of is a problem in the chart?

Schenk: Right. Well that makes sense. And for anybody out there that’s listening that’s maybe an attorney that is interested in contacting you, how would they get in touch with you?

Tory: Well my email address is my first one, tory@palivodalegalnurse.com. So tory@palivodalegalnurse.com. That would be my email. I have a web address, which is www.palivodalegalnurse.com. So either one of those, there’s a link on my website that somebody can contact me that way or just send me an email.

Schenk: Fantastic. And we’ll have that on the screen, but I just wanted to make sure that everybody could hear it that’s just going to listen and not watch, so we have that information for you.

Tory: Perfect.

Schenk: Well great, Tory. We really appreciate you coming on the show and giving us an overview of nursing home records and what family members of loved ones in nursing homes can expect if they acquire them and are looking over them.

Tory: Well thank you very much. I appreciate the opportunity.

Schenk: Awesome. Thank you so much, Tory. Have a good day.

Smith: Thank you, Tory.

Tory: Thank you.

Schenk: Bye-bye.

Tory: Bye-bye.

Schenk: Tory. Tory is an interesting name, like Tori Spelling, 90210.

Smith: Yeah. Yeah. I actually know a Tory in real life.

Schenk: I think there was also a wrestler named Tory, like WWE? And speaking of wrestling, I don’t know why I’m talking about this, but for some reason, I often use Google News as my news aggregate, and it allows just different things to come into my news feed. And for some reason, it won’t accept that I don’t want to learn about WWE and what’s going on with WWE and it refuses to believe me. Like I get like this is what’s happening in Congress and literally the next article is “What did Triple-H say to Vince McMahon this week on Smackdown?”

Smith: “I don’t care.”

Schenk: It’s like, how many times do I have to tell you I’m not interested in this news? I think that somebody, who’s the – Sergio? Who invented Google?

Smith: It’s two dudes.

Schenk: He must have invested in WWE.

Smith: Right.

Schenk: Like it won’t stop. It’s insane. So it’s gotten to the point now where I’m down to the F-list wrestling celebrities, like what’s Jake the Snake’s nephew’s neighbor doing at Smackdown.

Smith: But speaking of getting down to the bottom of something, we have gotten down to the bottom of this episode.

Schenk: How can somebody out there listen to this podcast?

Smith: So there are – and this is something I wanted to bring up – there are two methods, not just two ways that you can consume us. The first method is visually. You can go to YouTube – Schenk Smith at YouTube – or you can go to NursingHomeAbuse.com.

Schenk: No, you can’t. You can go to NursingHomeAbusePodcast.com.

Smith: NursingHomeAbusePodcast.com. Or you can listen to us, just the audio, on Spotify, iTunes, Pound Puppy, anything and anywhere that you typically get your podcast, Stitcher, anywhere.

Schenk: And I don’t know why I’m correcting you on this because it’s fictitious, but it’s not Pound Puppy, which was a famous doll in the early ‘80s that were like dogs that you would get from the pound. It’s Pop Puppies, which doesn’t exist.

Smith: I remember Pound Puppies. It was wherever I would go, he would go.

Schenk: That was my buddy, but that’s okay.

Smith: Yeah.

Schenk: Pound Puppies were good because they had a little hard plastic heart on the butt, and so when you hit your brother with it, that part really hurt. Anyways, that’s going to conclude now this episode of the Nursing Home Abuse Podcast. We will – yeah, with that, we’ll see you next time.

Smith: See you next time.

Schenk: See you next time for real.