Minnesota Nursing Home Clinical Record Requirements
Minnesota Nursing Home Clinical Record Requirements

Minnesota Clinical Record Confidentiality Regulation

Pursuant to Minnesota Administrative Rule 4658.0435 CONFIDENTIALITY OF CLINICAL RECORD AND INFORMATION, Subpart 1. Maintaining confidentiality of records, information in the clinical records, regardless of form or storage methods, must be kept confidential according to Minnesota Statutes, chapter 13 and sections 144.291 to 144.298 and 144.651, and federal regulations. A resident’s clinical information in a nursing home must be considered confidential but it must be made available to all persons in the nursing home who are responsible for the care of the resident. The clinical information must be open to inspection by representatives of the Department of Health and others legally authorized to obtain access.

Clinical Record Requirements for Nursing Homes

Subp. 2. Electronic transmission of health care data. If a nursing home chooses to transmit or receive health care data by electronic means, the nursing home must develop and comply with policies and procedures to ensure the confidentiality, security, and verification of the transmission and receipt of information authorized to be transmitted by electronic means. A durable copy of the transmission must be placed in the resident’s clinical record.

According to Minnesota Administrative Rule 4658.0445 CLINICAL RECORD, Subpart 1. Unit record. A resident’s clinical record must be started at admission and incorporated into a central unit record system. The clinical record must contain sufficient information to identify the resident, contain a record of resident assessments, the comprehensive plan of care, progress notes on the implementation of the care plan, and a summary of the resident’s condition at the time of discharge.

Subp. 2. Form of entries and authentication. Data collected must be timely, accurate, and complete. All entries must be entered, authenticated, and dated by the person making the entry. If a nursing home uses an electronic paperless means of storing the clinical record, the nursing home must comply with part 4658.0475. All entries must be made as soon as possible after the observation or treatment in order to keep the clinical record current. In cases where authentication is done electronically or by rubber stamp, safeguards to prevent unauthorized use must be in place, and a rubber stamp may be used only if allowed by the licensing rules for that health care professional. Nursing assistants may document in the nursing notes if allowed by nursing home policy.

Subp. 3. Classification systems. All diagnoses and procedures must be accurately and comprehensively coded to ensure accurate resident medical profiles.

Subp. 4. Admission information. Identification information must be collected and maintained for each resident upon admission and must include, at a minimum:

A. the resident’s legal name and preferred name;
B. previous address;
C. social security number;
D. gender;
E. marital status;
F. date and place of birth;
G. date and hour of admission;
H. advance directives, and Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, if any;
I. name, address, and telephone number of designated relative or significant other, if any;
J. name, address, and telephone number of person to be notified in an emergency;
K. legal representative, designated representative, or representative payee, if any;
L. religious affiliation, place of worship, and clergy member;
M. hospital preference; and
N. name of attending physician.

Common areas of cases I see include:  Falls from Beds, Hoyer Lifts and in the Bathroom; Sexual Abuse; Medication Errors and Others.  STOP ELDER ABUSE AND NEGLECT!

For more information about nursing home resident medical and clinical record confidentiality requirements or other questions about elder abuse and neglect contact Nursing Home Neglect Attorney Kenneth LaBore for a free consultation at 612-743-9048 or by email at KLaBore@MNnursinghomeneglect.com.

Nursing Home Clinical Record Rules in Minnesota
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