Fact Or Fiction? Reading Nursing Home Charts

If you are a nursing home resident, have an appropriate power of attorney, have the resident’s consent, or are the resident’s “personal representative,” you are entitled to inspect the resident’s “patient records.” The nursing home must permit “this inspection during business hours within five working days after receipt of the request.”

If you are a nursing home resident, have an appropriate power of attorney, have the resident’s consent, or are the resident’s “personal representative,” you are entitled to inspect the resident’s “patient records.” The nursing home must permit “this inspection during business hours within five working days after receipt of the request.”

Perhaps the best time to request inspection is when you are notified of a Care Conference, but a request may be made at any time. The request for inspection may be oral or written; the nursing home may have a form for the request. Regardless of whether the request is written or oral, make a note of when it was made and to whom it was made.

Nursing home charts are made up of many components. You should pay special attention to:

  • Care Plans;
  • Nurse’s Notes (sometimes called Progress Notes);
  • CNA charting (sometimes called ADL charting);
  • Medication Administration Records (sometimes called MARs); and
  • Treatment Administration Records (sometimes called TARs)

CARE PLANS:
Care Plans are supposed to help residents “attain or maintain the highest practicable physical, mental, and psychosocial well-being….” The nursing home must describe the resident’s needs and how those needs will be met. Compare what the nursing home says it will do with what is actually being done. You may find substantial discrepancies. If you do, bring them to the attention of nursing home staff and make notes.

NURSE’S NOTES:
Look for charting of anything unusual, such as a fall. Look for charting of changes of condition. If so, was the resident’s responsible person called? If you have noticed unusual occurrences or changes of condition, were they charted? Is the charting consistent with your observations? Bring discrepancies to the attention of nursing home staff and make notes.

CNA CHARTING:
This is a very important part of nursing home charting. It documents numerous activities of daily living (ADLs), including bathing, eating, repositioning, bowel and bladder function, toileting and more. Is the charting consistent with your observations? For example, does the charting document eating most or all meals, while you observe a significant weight loss? Does the charting document frequent repositioning, but your observation is that the resident is flat on his or her back all day? If the charting is not consistent with your observations, bring this to the attention of nursing home staff and make notes.

MEDICATION ADMINISTRATION RECORDS (MARs):
MARs document all medications ordered by the physician and all administrations of those medications. Review of MARs will tell you whether the nursing home staff says the ordered medications were administered, whether dosages were missed, and whether medications were refused. If your observations differ from what is charted, bring any discrepancy to the attention of facility staff and make notes.

TREATMENT ADMINISTRATION RECORDS (TARs):
TARs document all nonmedication treatments ordered by the physician. TARs document whether the nursing home staff says an ordered treatment occurred, whether it was missed, and whether a given treatment was refused. As is the case with MARs, if your observations differ from what is charted, bring any discrepancy to the attention of facility staff and make notes.

Competent and honest charting should provide a comprehensive view of a resident’s nursing home experience. However, nursing home charting is often inaccurate and incomplete and sometimes it is downright fraudulent, as when a nursing home continues charting “care” provided when the resident is no longer in the facility or has passed away.

Regular review of the nursing home chart will help you discover inaccuracies, incompleteness, or fraudulent charting. When you discover any of these, you should bring them to the attention of nursing home staff and make notes.

If you have questions concerning nursing home records, the care you or a loved one has received in a nursing home or if you or a loved one has been harmed in a nursing home, The Law Office of David M. Jamieson can help. Call 209-521-1269 to schedule a no cost, no obligation consultation.