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Clinical Records and Resident Access
Federal and state law, including statutes and agency regulations, regulate nursing homes. Under federal regulations, residents have the right to "a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility." 42 C.F.R. § 483.10. In order to live a dignified and self-determined existence, residents must be informed of their rights. These rights include a resident's right to access his or her medical records. A facility must maintain accurate clinical records that are readily available to residents upon request. This overview focuses on federal regulations regarding clinical records and resident access to these records.
Notice of Rights
Under federal law, a nursing home must inform a resident of his or her rights, including the existence of all regulations under which the facility operates. The notice must come when the resident first enters the facility, and periodically throughout the resident's stay. Generally, the facility must provide the resident with written and oral notice of rights. Additionally, the statement must be presented in a way which resident will understand. This means that the notice must be given in clear and common language. Finally, it must be clear that the resident understands his or her rights and the facility's services and responsibilities. 42 C.F.R. § 483.10(b).
Facility Record Keeping Requirements
Accurate record keeping is an important administrative duty, and it must be done in order to serve the resident, their family, and those who are treating the resident in the best manner possible. Accurate records will reduce the occurrence of misdiagnosis and incorrect treatments, and allow for a quick and accurate reference guide for facility workers.
Required standards and practices
According to the federal standards, a nursing facility "must maintain clinical records for all residents in accordance with accepted professional standards and practices." 42 C.F.R. § 483.75(l). This requires the nursing facility to maintain records that are:
- Complete;
- Accurately documented and recorded;
- Readily accessible; and
- Systematically organized.
In addition to the above-mentioned requirements, clinical records must be maintained for five years from the date of discharge, if there is no other differing state law requirement. 42 C.F.R. § 483.75(l)(2).
What makes up clinical records?
Clinical records are a compilation of a variety of sources. First, clinical records should include sufficient information to identify the resident. Second, the records should have all information about the resident's assessments and care plans. Third, the facility should maintain records of any pre-admission screening. This screening may be required under state law. Finally, the records should include any notes the facility keeps regarding the resident's progress. This may include physician and nurses' notes and daily log entries. 42 C.F.R. § 483.75(l)(5).
Safeguarding Requirements
According to federal standards, a nursing facility must safeguard clinical records against loss, destruction, or unauthorized use. This means that the facility must keep the clinical records confidential. 42 C.F.R. § 483.75(l)(4). It does not matter how the records are stored; however, they must be kept strictly confidential, except when required by:
- Transfer to another health care institution;
- Law;
- Third party payment contract; or
- The resident's own desire to see the records.
Resident Access to Records
Unfortunately, many residents and those who care for them are unaware of their right to access nursing facility records. According to federal regulations, "the resident or his or her legal representative has the right" to access "all records pertaining to him or her, including current clinical records." 42 C.F.R. § 483.10(b)(2).
A resident, or his or her legal representative, may make a written or oral request for records. The facility should grant access to the records within a 24-hour period, excluding weekends and holidays. Following the inspection of the records, the federal regulations grant the resident the right to photocopy the records. The cost of the photocopies should not exceed the "community standard" for photocopies. 42 C.F.R. § 483.10(b)(2)(i).
If you are experiencing difficulty accessing the medical records of a nursing home resident, an experienced elder law attorney can provide guidance and advice regarding your legal options.
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Clinical Records and Resident Access
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