Organizing Medical Records:
Nursing Home Records
Nursing home records can be much more complex and more time-consuming for Legal Nurse Consultants to organize than other types of medical records. Because the resident's stay might be months or years, nursing home records are often voluminous. Many nursing homes don't have a medical records department so when the chart is thinned, the thinned records many be stored "as is" and not put into any particular order. Since the records may be thinned numerous times over the course of the resident's stay, the records may be very mixed up by the time the LNC receives them.
Nursing home records have different chart sections than other organizations and the contents may be different from their hospital counterparts. Below are categories that can be used to organize nursing home records. The categories and order can be altered to LNC or attorney preference.
Admission face sheet.
Living Will. Although this form may have been signed prior to admission, it can be placed behind documents from the admission date.
Durable Power of Attorney. This form may also have been signed prior to admission.
Leave of absence forms
Transfer forms generated by the nursing home when it is sending a resident to a hospital. These should be the last forms in this section.
Prior and Hospital Records
Transfer records generated by the hospital to the facility
Emergency Room records
Other hospital records. If there are a number of documents from one admission, ensure that the records are grouped in sections (progress notes, nurses notes, etc.) as well as chronologically.
Place pre-printed orders first.
Telephone orders are placed after pre-printed orders unless the telephone orders are grouped by month. In that case, place them behind the corresponding printed orders for that month. There may be three to four months of orders mounted on a single sheet that are not in chronological order, which is why these are put in the back of all the printed orders.
Miscellaneous orders are placed after telephone orders. These might include faxed or written requests signed by the physician for dietary changes and therapies.
Physician Progress Notes
The initial history and physical is first in this section. Annual histories and physicals are placed within the attending's progress notes if they easily fit there. If not, they can be placed after the initial history and physical.
Progress notes by the attending physician, physician assistant or nurse practitioner are placed next in chronological order. The attending's discharge note can be placed after the progress notes.
Consults are placed at the end of this section unless the consultants notes are interspersed within the attending's notes. When possible, group consultant notes into the following sections:
Minimum Data Sets (MDS) and Resident Assessment Protocols (RAP)
MDS, RAP trigger legends and RAP summaries are placed in this section chronologically.
Ensure that RAPs go in the same order as listed on the RAP legend and that they go directly after the MDS for which they were generated.
Don't use the signature date when determining the date of the MDS. Instead use the Assessment Reference Date, which is found on the second or third page of the form.
These can be placed in chronological order.
An alternate way to organize them is to group them by problems such as risk for falls or skin breakdown, but they should be in chronological order within each grouping.
Nursing Assessment / Nursing Notes
The nursing assessment usually consists of a form that is completed upon admission to the nursing home and when the resident is re-admitted after a hospital admission. Do not group nursing assessment forms. Place the initial nursing assessment first and additional nursing admission forms chronologically within the nurses notes.
Sometimes quarterly care plan updates or skin summaries will be documented on the nursing notes form. In addition, the same form may be used by Social Services, Recreational Therapy and Dietary. Those records should be put into their respective sections of the medical record rather than the nursing notes sections.
Weekly or monthly summaries, if available, should be placed at the end of the nursing notes section.
Medication Administration Records (MAR)
Monthly MARs are first in this section.
Narcotic count sheets and pharmacy notes are placed behind the monthly MARs. If there is more than one controlled substance being administered, place the same drug sheets together (i.e., all Ativans, Haldols, etc.) separated and in chronological order within their own group.
If the resident is on psychotropic drugs, the facility may have Behavior / Side Effects records. Place these behind the applicable month.
Treatment Administration Records (TAR)
If MARs and TARs are intermixed, separate them into separate sections.
Pre-printed TARs followed by hand-printed treatment records are organized by each month.
Decubitus / Skin Reports Order as follows:
Norton / Braden scale reports
Bi-weekly skin checks
Decubitus reports. Group decubitus reports according to the location of the wound with any photos of that particular wound behind the documentation for that site.
At Risk for Fall / Restraint Assessment / Side Rail Assessment
These can all be grouped together.
Keep all the "at risk" assessments together, all restraint assessments and all side rail assessments together with each group of documents in chronological order.
Vital Signs / Weight / Intake and Output
Vital signs may be documented on separate forms than weights but sometimes they are together. If they are not, make sure they are separated and in chronological order.
I&O records are grouped together after weights.
Sometimes you will find a form that might not fit into any of the above categories.
Place miscellaneous assessments such as neurological checks/AIMs testing, neurological testing, pain assessments, bowel and bladder assessments etc. in this section.
These include Physical Therapy, Occupational Therapy, Speech Therapy, and Respiratory Therapy.
Generally, every quarter, each discipline will screen the resident. These screens are most often found on a Screening sheet, which has a spot for each discipline. You can put all of these in the front unless only one department did the screening. If so, that screening sheet would go with the discipline involved.
Group by discipline after the screening sheet.
Place swallow studies after Speech Therapy notes.
Examine these carefully. They can be confused with the therapy notes. Not all medical records will have restorative nursing notes.
The initial dietary assessment is followed by the narrative dietary notes.
Some facilities have food consumption sheets, which can be place after the narrative dietary notes.
Dietary notification slips can be organized in chronological order and placed at the back of the dietary section.
Activities (Recreational Therapy)
Start with the initial activities assessment followed by quarterly assessments.
Put the narrative section after these documents.
Place lab results chronologically by the date the specimen was collected.
Ensure that lab results are documents generated from the facility and not from a previous or interim hospitalization. Many nursing homes do not draw their own labs; they are drawn by an outside company.
Ensure that the x-rays were generated during the facility admission and not from a previous hospital admission.
If there are any other tests such as EMGs, EKGs, etc., place them behind the x-ray section.