The short answer
A nursing home chart is made up of many separate records, most of them now electronic. The key parts are physician orders, physician and nursing progress notes, the medication and treatment administration records (MAR and TAR), nursing assistant flow sheets, the MDS assessments, care plans, skin and wound records, weights and intake records, fall and incident documentation, labs and hospital transfer forms.
The main parts
- Physician orders. Every medication, diet, treatment, test and precaution must be ordered. Telephone orders are written by a nurse and later signed by the practitioner.
- Progress notes. Notes by physicians, nurse practitioners, nurses, social workers, dietitians and therapists describing the resident's condition and events.
- MAR and TAR. The record of each medication dose and each treatment (such as a wound dressing) and whether it was given.
- Nursing assistant flow sheets. Shift-by-shift documentation of bathing, eating, toileting, incontinence care and repositioning.
- MDS assessments and care plans.
- Skin and wound records. Weekly skin checks, Braden Scale risk scores, and wound measurements, descriptions and photographs.
- Weights, intake and output. Weekly or monthly weights, the percentage of each meal eaten, and fluid intake.
- Fall risk assessments and post-fall notes. Note that the facility's internal incident report itself may be kept outside the chart.
- Labs, x-rays and consultations, and hospital transfer forms sent with the resident to the emergency room.
- Admission documents, including the admission agreement and any arbitration agreement, and advance directives such as a health care proxy or MOLST.
What families often miss
- Electronic records have an audit trail showing who entered or changed each entry and when. Late entries and edits made after an injury can matter.
- Blanks are information. A blank box on a flow sheet or MAR usually means the task was not documented, and often that it was not done.
- "Charting by exception" means some facilities only write a note when something is abnormal. Ask how the facility documents.
How to get the chart
Residents and their legal representatives have the right to see the record within 24 hours and get copies within two working days. After a death, the executor, administrator or a close family member can request the records. Our free kit generates the request letter.
The rules behind this
- 42 C.F.R. § 483.10(g)(2) (access to records)
- 42 C.F.R. § 483.70(i) (medical records)
- New York Public Health Law § 18
Related questions
This guide provides general information, not medical or legal advice. Rules change; confirm current requirements with the facility, the New York State Department of Health or a professional. Attorney Advertising.