Maintaining residents clinical records
In addition to maintaining a financial record on each resident, you must also keep a healthcare record for each resident who receives care services in your community. This should be an all-encompassing medical record that is easily accessible to care team members in the community to provide them with knowledge of care needs for each resident. Check out the following regulation provided by Indiana RCFL for what is to be included in the healthcare record as well as how to safely store and maintain said record:
410 IAC 16.2-5-8.1 Clinical Records
(a) The facility must maintain clinical records on each resident. These records must be maintained under the supervision of an employee of the facility designated with that responsibility. The records must be as follows:
(1) Complete.
(2) Accurately documented.
(3) Readily accessible.
(4) Systematically organized.
(b) Clinical records must be retained after discharge:
(1) for a minimum period of one (1) year in the facility and five (5) years total; or
(2) for a minor, until twenty-one (21) years of age.
(c) The facility must safeguard clinical record information against loss, destruction, or unauthorized use. (d) The facility must keep confidential all information contained in the resident ‘ s records, regardless of the form or storage method of the records, and release such records only as permitted by law.
(e) The clinical record must contain the following:
(1) Sufficient information to identify the resident.
(2) A record of the resident ‘ s evaluations.
(3) Services provided.
(4) Progress notes.
(f) The facility shall have a policy that ensures the staff has sufficient information to meet the residents ‘ needs.
(g) A transfer form shall include the following:
(1) Identification data.
(2) Name of the transferring institution.
(3) Name of the receiving institution and date of transfer.
(4) Resident ‘ s personal property when transferred to an acute care facility.
(5) Nurses ‘ notes relating to the resident ‘ s:
(A) functional abilities and physical limitations;
(B) nursing care;
(C) medications;
(D) treatment; and
(E) current diet and condition on transfer.
(6) Diagnosis.
(7) Date of chest x-ray and skin test for tuberculosis.
(h) Current clinical records shall be completed promptly, and those of discharged residents shall be completed within seventy (70) days of the discharge date.
(i) A current emergency information file shall be immediately accessible for each resident, in case of emergency, that contains the following:
(1) The resident ‘ s name, sex, room or apartment number, phone number, age, or date of birth. (2) The resident’s hospital preference.
(3) The name and phone number of any legally authorized representative.
(4) The name and phone number of the resident’s physician of record.
(5) The name and telephone number of the family members or other persons to be contacted in the event of an emergency or death.
(6) Information on any known allergies.
(7) A photograph (for identification of the resident).
(8) Copy of advance directives, if available.
(j) If a death occurs, information concerning the resident ‘ s death shall include the following:
(1) Notification of the physician, family, responsible person, and legal representative.
(2) The disposition of the body, personal possessions, and medications.
(3) A complete and accurate notation of the resident ‘ s condition and most recent vital signs and symptoms preceding death.
(k) The facility shall store inactive clinical records in accordance with applicable state and federal laws in a safe and accessible manner. The storage facilities shall provide protection from vermin and unauthorized use.
Top Takeaways:
- (b) Clinical records must be retained after discharge:
- for a minimum period of one (1) year in the facility and five (5) years total;
Your work is not done when a resident discharges from the community- you must ensure the safety of each resident record for s period of 5 years after discharge. There is potential the record will need to be subpoenaed in litigation and necessary for the court to review.
- (e) The clinical record must contain the following:
(1) Sufficient information to identify the resident.
(2) A record of the resident ‘ s evaluations.
(3) Services provided.
(4) Progress notes.
The residents clinical record is meant to store all pertinent information related to the residents’ care. The document should be all encompassing and cover the needs of each resident.
- (7) A photograph (for identification of the resident).
Facilities are often cited for their inability to have a photograph on file for each resident. You may think this is a minor issue- but it could turn into a life saver if a resident goes missing or during an evacuation type of situation.