The Purpose and Meaning of Medical Record Documentation
Jeannine LeCompte, Compliance Research Specialist
Keeping a complete medical record of all treatments and conditions to which a resident is subjected is not only good ethical practice and a legal requirement—but can also play a major role in protecting a Skilled Nursing Facility (SNF) from legal trouble.
All medical records should at the very least provide the following data:
– Essential information for resident care
– A legal record to support care and services provided to the resident;
– An objective narrative of the resident’s progress toward goals in the plan of care; and
– A comprehensive review of services provided by all medical professionals providing service to the resident.
CMS’s requirements on medical records are stipulated in the Code of Federal Regulations (CFR) 42, §483.70(i)(1), which demands that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are:
– Complete;
– Accurately documented;
– Readily accessible; and
– Systematically organized.
The Joint Commission—which accredits and certifies nearly 21,000 healthcare organizations and programs in the US—states that all documentation should reflect the collaborative planning and provision of care and treatment, while the American Nurses Association (ANA) provides an equally handy checklist which spells out the basic requirements of all documentation:
– Systematic
– Continuous
– Accessible
– Communicated
– Recorded, and
– Readily available to all healthcare team members.
Meeting all these requirements means that staff have to be trained and made fully aware that every event in the life of a resident or patient must be documented, and matched up with the overall condition and lifestyle prerequisites of that person.
The law demands that these records must contain:
– Sufficient information to identify the resident;
– A record of the resident’s assessments;
– The comprehensive plan of care and services provided;
– The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
– Physician’s, nurse’s, and other licensed professional’s progress notes; and
– Laboratory, radiology, and other diagnostic services reports as required under § 483.50 of the law.
In addition, these records must be safeguarded against loss, destruction, or unauthorized use; and be retained for the period of time required by state law (or for five years where there is no such state requirement)—and, in the case of a minor, for three years after he or she reaches legal age under state law.
Comprehensive record-keeping will also provide an important level of protection for the facility against civil litigation as well as criminal prosecution from state agencies.
The slogan “If it wasn’t documented, it didn’t happen” should be imprinted upon the consciousness of all staff—because the future of their facility and their own employment might very well one day depend on it.
