Key differences between NH and hospital records

If you have never worked in the long term care environment a glance into the medical chart might be intimidating. Flipping through the records in a nursing home chart will reveal many documents specific to this nursing specialty. Some nurses without long term care experience are very hesitant to review one of these cases due to the lack of understanding the purpose of these industry-specific records. Once you understand where important information is located within these medical records you can use them to support your analysis of the matter.

One of the most mystifying records within a nursing home chart is the Minimum Data Set, most often simply referred to as the MDS. This document is a comprehensive assessment of the resident’s functional abilities, cognitive status, indicators of delirium, fall history, ADL status, diagnoses, wounds, nutritional status, restraint use, continence status, and more. The nursing and therapy notes and other documentation should be reviewed to ensure the information in the MDS is accurate.

The data collected in the MDS is utilized to create a Resident Assessment Protocol, also known as the RAP, which provides the foundation for creation of the resident’s individualized care plan. The MDS triggers any risk potential that should be addressed on the care plan. The staff may override the trigger or decide to proceed and create a plan of care. For example, a RAP may be triggered based on recent weight loss. However, the staff may override the trigger by indicating a recent history of bilateral above the knee amputations, thus justifying the recent weight loss or less than ideal body weight status. The RAP should be reviewed to ensure that all potential risks have been appropriately triggered and addressed in the plan of care.

While the Plan of Care (POC) is not paperwork specific only to long term care, it is a very critical document and must be closely reviewed to ensure every risk unique to that resident has been addressed and that the POC is individualized to the specific needs of that resident. The care plan is a dynamic tool that should be updated as the needs of the resident change. For example, if the resident is at risk for falls and the goal indicates the resident will have no falls with injury within the next 90 days and that resident does indeed fall and sustained injury, the plan of care must be updated. You should expect to see new interventions to prevent falls.

Therapy records are critical to long term care case. When a resident is involved in PT, OT or ST you will find frequent documentation which can be crucial, especially when there are few nursing and physician notes. Therapy notes will usually describe the resident’s functional ability, level of pain, subjective statements, cognitive status, and safety recommendations. Always be sure to review the therapy records thoroughly and compare these assessments to the nursing notes, physician notes, MDS and care plan. Likewise, important information may be found in the social services notes as documentation regarding discharge plans, family concerns, and social history is likely recorded in this section.

Don’t allow your lack of familiarity with long term care records hold you back from an interesting case review. Your knowledge of the records outlined above will provide you the ability to thoroughly understand the residents’ needs and determine whether they were met. This information is just a brief overview of a few of the records. However, part of being successful is self-educating and knowing how to find the information you need. Identifying a long term care nurse that you can call with questions as needed might just provide you with the added confidence needed to say “Yes” when asked to review a nursing home case.

Angie Duke-Haynes, RN is Principal, Legal Nurse Consulting Institute, LLC and co-presenter of an all new webinar on polishing your writing skills. Learn more about record reviews and how to WOW clients by signing up for a webinar how to polish your writing skills. See www.PatIyer.com for details.