Clinical Record Requirements for Resident Charts in Nursing Homes
Federal Regulations for Clinical Records for Nursing Home Residents
Pursuant to federal regulation 42 CFR 483.70(i), clinical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are—
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized.
(2) The facility must keep confidential all information contained in the resident’s records, regardless of the form or storage method of the records, except when release is—
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.
(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use;
Clinical Record Retention Regulations
(4) Medical records must be retained for—
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.
(5) The medical record must contain—
(i) Sufficient information to identify the resident;
(ii) A record of the resident’s assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician’s, nurse’s, and other licensed professional’s progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
For more information about nursing home 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.