Long-Term Care Facilities Virginia

Records

 

Glenburnie Records

 

I.         Form

A.       Computer

B.       Binder

II.        Content

A.       Assessments

1.       Entry

2.       Periodic

a.        Annual Comprehensive

b.       Quarterly Review

3.       Condition change

4.       Transfer

5.       Re-entry

6.       Discharge

B.       Care Plan

Review and update with each assessment

C.       Orders

D.       CNA Instructions

E.        Other

Nursing Home Medical Records: A Primer

III.      Administration

A.       Medical: doctor, practioner

B.       Wound Care: wound care doctor

Separate database

C.       Nursing: nurse

D.       Daily Living Care: CNA

E.        Compliance: MDS / Care Plan Office