What are in nursing home medical records?

Episode 186
Categories: Regulations, Resources

As a resident or resident representative, you have the right to request and review nursing home medical records. Unfortunately, these documents can be a garbled mess. On this week’s episode, we discuss what document categories are contained in a nursing home chart, what role each plays in care, and what to look out for.

Schenk: Hello out there. Welcome back to the podcast. My name is Rob. I’m going to be your host for this episode. We’re going to be delving into the categories of documents that are in your loved one’s medical records or chart as we would call it as well. What are those documents? What can they tell you about the care that’s being received by your loved ones and other pertinent information?

Before we get into it, let’s talk about what you can do to help out this podcast. The number one thing you can do to help out this podcast is to like and subscribe wherever you get your podcast from. If you are enjoying the content, please be sure to leave a review, let us know how we’re doing. If you have a suggestion for content, please email us. Check us out on YouTube. Leave a comment there. Let us know what you want us talk about. We’d be more than happy to address any questions that you might have in a future episode. So we appreciate you doing that.

Now with regard to today’s topic, we are talking about medical records that the typical nursing home resident would have, and upon requesting them, what to be looking out for, what is in them. It’s a smorgasbord of information.

Who can request nursing home medical records?

So first, we need to talk about who can request a resident’s medical records? We addressed the issue of requesting medical records in previous episodes. I think we had attorney Ryan Locke on here a couple years ago on an episode dealing with requesting medical records, but the long and short of it is the resident can request their own records. The resident’s personal representative can request the record. Unless it is the resident or the personal representative of the resident, no one else can request medical records. It is prohibited by law. There’s a law called HIPAA that protects the privacy of medical records.

So who qualifies as a personal representative of the resident? Just for the fact that someone is a family member does not make them a personal representative. The nursing home often acts that way but from a technical standpoint, the nursing home is justified in denying a family member’s request for records if they do not have the proper authority to be a personal representative.

Being a personal representative and being able to request those documents requires some type of written authority, whether that’s guardianship, which we’ve talked about in previous episodes, or some type of power of attorney, which we’ve also talked about in previous episodes. So if you want more about how to become a personal representative with the authority to request the documents, check out episodes that are linked below. Otherwise we’re going to assume that you have the proper authority and that you have in fact correctly requested the records and you have now received them and they’re spread out on your kitchen table and you’re trying to make heads or tails of them.

What are in nursing home medical records?

So nursing home records, what we would also call the chart, is all of the documents pertaining to the medical treatment of your loved one at that facility. When you ask for medical records, you’re typically going to get hundreds of pages. Not included in those are going to be things not related to the medical treatment. So if you ask for medical records, you’re probably not going to get the admission file, the business records like the contract between the resident, your loved one, and the nursing home itself, or those disclaimers and documents regarding Medicare eligibility. That kind of stuff is in the business file typically, so you’re probably not going to get those if you get medical records.

Also not within the medical records are going to be incident reports, most often, or inspection reports or items that deal with investigation of incidents involving your loved one. Those are documents that are outside, typically, of the medical records, of the chart. So those are categories that you will not find in the medical records. Medical records are pretty solidly only dealing directly with the treatment.

There are many categories of documents and each facility might call that category something a little different. So I’m going to be talking in generalities about these categories, however, these are things that should be in every single medical record no matter what the facility is, although again, the specific name of the document might be a little different from facility to facility.

What are physician’s orders?

The first category of documents that should be contained within the medical records are physician’s orders. Physician’s orders are documents that essentially detail what the doctor is instructing that nursing home to do with regard to medication prescriptions and treatments. A physician’s order often takes the form of a telephone notation, a fax or an actual written document with the physician’s letterhead. But at the end of the day, it is a series of instruction sand signed off by that physician. So sometimes you’ll see something like, “One tab of aspirin once a day for six weeks,” or “Change bandage three times a week or as needed.” These are physician’s orders if they’re signed by the physician.

I would say this is one of the critical categories of documents to read and understand, and if you don’t understand them, ask questions. “Well it says here in this physician’s order that you’re supposed to provide my loved one with oxycodone,” or “You’re supposed to provide my loved one with an antibiotic. I haven’t seen you do that today. Has it been done? Are you doing that?” Physician’s orders are critical in the treatment and care of your loved one and they are required to be every medical record.

Also required to be in every medical record as it pertains to physicians are what’s called physician’s progress notes. We’ve talked about in previous episodes that the attending physician is required to visit your loved one periodically. Typically it’s every 60 days. They need to either be face-to-face with your loved one or delegate that task to someone with the appropriate authority to do so, like a nurse practitioner.

At that time, the physician is required to jot down notes about any new diagnoses, any observations that they have made. And sometimes these physician’s notes can have important information and updates on the clinical condition of your loved one. So they might be called something different in your medical chart. It might be called “doctor’s notes,” “progress notes,” “physician’s notes,” whatever the case may be, look for a category of documents that are either written or dictated by the physician and signed by the physician that talks about the physician having visited your loved one and what they observed – physician progress notes.

What are assessments?

The next category is extremely important, and these are assessments. In medical charts, the assessment can take a couple of forms. There is a particular type of document that is called the minimum data set or MDS, and it looks like a computerized form that can be between 20 pages and about 50 pages that details the head-to-toe functioning of your loved one. You’ll know it because typically depending on if you get color copies, it’s kind of a reddish color and it says “MDS” at the top and it’s very long and very involved. And some of it feels like it’s gibberish but it’s extremely important. It details everything from skin condition to cognitive ability to functional ability, what your loved one is physically able to do with regard to activities of daily living, the MDS.

The MDS is a required assessment by the federal government because it helps the government understand how much money they need to provide this nursing home for care.

Now that’s one way that you can see that assessments have been done. The other way is other assessment forms, so there could be what’s called Braden assessments, meaning there is a document that assesses the skin integrity of your loved one and the likelihood that they may develop pressure injuries, a Braden scale. Or it might just say “wound risk assessment.” So in other words, outside of the MDS, which is required to be in the medical records, there could be other documentation that further details those assessments, so there could be a fall risk assessment done that’s multiple pages or one page.

So assessments is the category we’re talking about – MDS is within that category, and then you can look for other documents that might be in there pertaining to assessments. And assessments just mean that they have looked at medical records, they have interviewed the resident and they’ve observed the resident to determine the various risks to certain problems and the types of treatments that will need to be put in place based on the assessment. So assessments, required to be in the medical records – look out for them.

What are care plans?

Next is care plans. A care plan is required to be in those medical records. We’ve talked about care plans in multiple episodes. I would say that the care plan, aside from the physician’s orders, the care plan is the most critical document in the medical records. This is a document you need to – you can push all the other documents away and really study this one. Hang it up on your refrigerator. The care plan details the objectives, the goals and the interventions, meaning the treatments that your loved one needs to get in order to maintain or improve their baseline.

For example, a care plan might say, “Resident is at risk for fall. Our goal is to make sure the resident does not fall for the next 90 days. Here are the things that we’re going to do to prevent the resident from falling. We’re going to monitor for continent care. We’re going to make sure the call light button is always accessible to the resident. We’re going to monitor – we’re going to routinely monitor every two hours.” It’ll have a list of things they’re going to do in order to meet the objective of the resident not falling.

So understanding that, you can go into that nursing home and make sure they’re doing what they’re saying they’re going to be doing to achieve that objective. And unlike other parts of the medical records, the care plan is written in plain English. The care plan is being read by multiple staff members that have varying degrees of education, varying degrees of training. So there is incentive to make the document readable for everybody, and that includes you. It is a document that you should be able to sit down and read, and I’m telling you that if you can’t understand it, that’s on the nursing home. That’s not on you. You need to be able to take that document and the document is likely to say “care plan” on it somewhere. There’s not a lot of ways that you can describe it other than saying it’s a care plan. So “care plan” should be written somewhere on that document.

Again, super critical that you read it, understand it, print it out, have it with you, put it in a folder, make sure that when you go to visit your loved one, you ask them about it. Has the care plan changed? Are you still doing X, Y and Z because it says you’re still supposed to do it for 90 days? We’re past 90 days – are you still doing it? – this type of thing. If you get any gruff about that, if you get answers that don’t sound satisfactory, you will need to schedule an appointment with the director of nursing, with the administrator, with the charge nurse to go over the issues that you’re having. But the care plan along with those physician’s orders is one of the critical documents for you to have and to understand.

What are nurse notes?

The next category of documents that are going to be contained in the medical records are the nurse notes. Nurse notes are – and this could be called progress notes, nurse’s notes, nurse notations, whatever the case may be, this is where nurses on typically a daily basis but sometimes on a shift by shift basis, sometimes on a weekly basis, will jot down notes pertinent to the care of the resident.

So for example, a nurse note might say, “Resident had trouble falling asleep tonight. Resident only ate 25 percent of their dinner. Resident was aggressive towards their roommate today. He threw a cup of water at the resident.” Notes that are typically out of the ordinary.

But there could also be notes in there that are extremely ordinary because no two facilities are going to document things the same way. So some facilities, vital signs will appear in the nurse notes, vital signs being like blood pressure readings, pulse rate, temperature, things like that can be contained in the nurse notes. But nurse notes are just a category that you should look out for and read because sometimes things might not be the truth in them. I often ask my clients – the nurse notes will say, “Spoke with the family today about resident falling and hurting themselves,” and the client, the family member will say, “I never got a phone call about that. I never talked to anybody about that. That is a lie.” So it’s important to periodically look at the nurse notes, make sure that things appear accurate, and if they don’t appear accurate, make it known to the staff at that time.

What are medication and treatment administration records?

The next category are medication administration records and treatment administration records. These to me are the ones that are the most difficult to understand and read, but essentially these are documents that detail and document that prescription medications or treatments that are required under the physician’s orders are being done.

For example, if the physician’s orders say a particular medication should be administered at the start of every shift, then there will be a medication administration record that has little squares for each shift and they should initialed or check-marked along with whatever that medication is to show that it was provided every shift and then it should have, the document should have a number of days that prescription runs that should indicate that medication was administered as it was supposed to, and that should be the case for every medication. It should be the case for every treatment.

Sometimes the physician’s order or the care plan will say, “Document side effects of medication.” Then in your medication administration records, the treatment administration record, there will be a corresponding place where the side effects are documented. So for example, “Shift 2 on December 22, resident lethargic due to medication,” things of that nature. So the medication administration records and treatment administration records are important to understand whether or not things are getting done, but these are, in my opinion, some of the most difficult documents to make heads or tails of because it’s being signed multiple times a day, maybe multiple times a week. It’s getting shuffled around. No two facilities look the same, so I’ve always in my experience had a little bit more difficulty than normal reading those.

So that is most of the medical records. Now sometimes you’re going to have documents, as I mentioned, sometimes they’ll include incident reports or S-bar reports in the medical records. I would say that’s often a mistake on the part of the nursing home if you receive those, because most of the time they want to keep those. But if you have them, look at them.

So the incident report, or the S-bar report, is just a document that details a significant change in the resident’s condition and what was done. So it might say, “Altered mental status at 3:52 p.m. EMS was called. This is not baseline for this resident, etc.” And it provides you kind of a timestamp of what the nursing home did based on that change in the baseline, based on that significant change in condition. So S-bars, incident reports, these types of things you’ll sometimes find in the medical.

But again at the end of the day, you won’t be able to have any of these unless you ask for them, and in order to ask for them, you need to have the appropriate authority. In order to have the appropriate authority, you need to have the appropriate authoritative documents. And I would recommend you check out episodes where we talk about where to get those documents.

And again, super important to be involved in the planning of care and understanding that care plan. That’s super critical because no one loves your loved one like you do – not the facility, not the doctor, not the attending physician. Only you. So it’s going to be up to you to make sure that that nursing home is doing everything that’s written in that care plan and everything that’s written in those physician’s orders. And if they’re not, it’s up to you to rattle the cages. And getting the medical records, understanding the categories of documents in them is going to help you rattle those cages.

I hope you found this episode informative and if you’re enjoying the content of these episodes, please be sure to like and subscribe wherever you get your podcasts from. New episodes twice a month on Mondays. We’ll see you next time? Yeah, that’s it. So folks, we’ll see you next time.