Long-Term Care Facilities – Virginia




Nursing Home Medical Records: A Primer

by TEI Expert - June 14, 2016


Information usually in a resident’s medical record:


I.         Administrative Information.

A.       admission face sheet

B.       leave of absence forms

C.       consents

D.       hospital transfer forms

E.        advance directives

1.       durable power of attorney

2.       do not resuscitate

3.       do not intubate

4.       do not hospitalize

5.       living wills

II.        Prior Hospital Records

A.       emergency room records

B.       transfer records

C.       other hospital records

III.      Physician Orders

A.       pre-printed (monthly orders)

B.       telephone orders

C.       miscellaneous orders

1.       fax correspondence to pharmacy

2.       dietary changes

3.       therapy orders

IV.      Physician Progress Notes

A.       initial history and physical

B.       progress notes

V.       Consultations

A.       admission dental

B.       dental

C.       ophthalmology

D.       optometry

E.        surgical

F.        podiatry

G.       psychiatry

VI.      Minimum Data Sets, Care Area Assessments

A.      initial

B.       annual

C.       significant change

VII.    Care Plans

A.       routine

B.       care plan for each skin concern

VIII.   Nursing Assessment

A.       admission assessment

IX.      Nursing Notes

A.       notes

B.       monthly/quarterly summaries

X.       Medication And Treatment Administration

XI.      Skin Integrity Status

A.       skin risk assessments

B.       weekly check record

C.       pressure ulcer documentation

XII.    Other Risk Assessments

(admission / re-admission and quarterly)

A.       wandering/elopement

B.       fall

C.       pain

D.       incontinence

E.        dehydration

F.        fecal impaction

G.       urinary tract infection

H.       chocking/aspiration

XIII.   Vital Signs, Weights, Intake/Output Records

XIV.  Therapy

(physical, occupational, speech, respiratory)

A.       admittance screen

B.       issue screens

C.       bi-weekly progress notes

D.       discharge summary

E.        miscellaneous information

XV.    Dietary

A.       initial assessment

B.       issue assessments

C.       progress note

XVI.  Activities And Recreational Therapy

A.       initial assessment

B.       issue assessments

C.       progress notes

D.       quarterly updates

XVII. Social Services

A.       initial assessment

B.       progress notes

C.       quarterly updates

D.       burial arrangements

XVIII.           Laboratory, X-Rays, Other Diagnostic

XIX.  Nursing Assistant Documentation

XX.    Miscellaneous Documents