– Laboratory, radiology, and other diagnostic services reports as required under § 483.50 of the law.
– Physician’s, nurse’s, and other licensed professional’s progress notes and – The results of any preadmission screening and resident review evaluations and determinations conducted by the State – The comprehensive plan of care and services provided – A record of the resident’s assessments – Sufficient information to identify the resident
The law demands that these records must contain: Meeting all these requirements means that staff have to be trained and made fully aware that every event in the life of a resident or patient must be documented, and matched up with the overall condition and lifestyle prerequisites of that person. – Readily available to all healthcare team members. The Joint Commission-which accredits and certifies nearly 21,000 healthcare organizations and programs in the US-states that all documentation should reflect the collaborative planning and provision of care and treatment, while the American Nurses Association (ANA) provides an equally handy checklist which spells out the basic requirements of all documentation: – A comprehensive review of services provided by all medical professionals providing service to the resident.ĬMS’s requirements on medical records are stipulated in the Code of Federal Regulations (CFR) 42, §483.70(i)(1), which demands that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are: – An objective narrative of the resident’s progress toward goals in the plan of care and – A legal record to support care and services provided to the resident – Essential information for resident care Keeping a complete medical record of all treatments and conditions to which a resident is subjected is not only good ethical practice and a legal requirement-but can also play a major role in protecting a Skilled Nursing Facility (SNF) from legal trouble.Īll medical records should at the very least provide the following data: Jeannine LeCompte, Compliance Research Specialist The Purpose and Meaning of Medical Record Documentation
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