Assisted Living Contents of Resident Record - Minnesota Nursing Home Law Abuse and Neglect Attorney

Contents of Resident Record.

According to Minn. Stat. 144G.43, Subd. 3, contents of a resident record include the following for each resident:

(1) identifying information, including the resident’s name, date of birth, address, and telephone number;

(2) the name, address, and telephone number of the resident’s emergency contact, legal representatives, and designated representative;

(3) names, addresses, and telephone numbers of the resident’s health and medical service providers, if known;

(4) health information, including medical history, allergies, and when the provider is managing medications, treatments or therapies that require documentation, and other relevant health records;

(5) the resident’s advance directives, if any;

(6) copies of any health care directives, guardianships, powers of attorney, or conservatorships;

(7) the facility’s current and previous assessments and service plans;

(8) all records of communications pertinent to the resident’s services;

(9) documentation of significant changes in the resident’s status and actions taken in response to the needs of the resident, including reporting to the appropriate supervisor or health care professional;

(10) documentation of incidents involving the resident and actions taken in response to the needs of the resident, including reporting to the appropriate supervisor or health care professional;

(11) documentation that services have been provided as identified in the service plan;

(12) documentation that the resident has received and reviewed the assisted living bill of rights;

(13) documentation of complaints received and any resolution;

(14) a discharge summary, including service termination notice and related documentation, when applicable; and

(15) other documentation required under this chapter and relevant to the resident’s services or status.

Transfer of Resident Records

Pursuant Minn. Stat. 144G.43, Subd. 4, with the resident’s knowledge and consent, if a resident is relocated to another facility or to a nursing home, or if care is transferred to another service provider, the facility must timely convey to the new facility, nursing home, or provider:

(1) the resident’s full name, date of birth, and insurance information;

(2) the name, telephone number, and address of the resident’s designated representatives and legal representatives, if any;

(3) the resident’s current documented diagnoses that are relevant to the services being provided;

(4) the resident’s known allergies that are relevant to the services being provided;

(5) the name and telephone number of the resident’s physician, if known, and the current physician orders that are relevant to the services being provided;

(6) all medication administration records that are relevant to the services being provided;

(7) the most recent resident assessment, if relevant to the services being provided; and

(8) copies of health care directives, “do not resuscitate” orders, and any guardianship orders or powers of attorney.

Record Retention

Following the resident’s discharge or termination of services, an assisted living facility must retain a resident’s record for at least five years or as otherwise required by state or federal regulations. Arrangements must be made for secure storage and retrieval of resident records if the facility ceases to operate.