Nursing Facilities
1
The facility must maintain medical records that are:
Accurately Documented
Readily Accessible
Systematically Organized
Complete
2
All information contained in the resident's record must be kept confidential, except when release is permitted or required.
3
The facility must safeguard medical records against loss, destruction or unauthorized use.
4
Medical records must be retained for the required or designated timeframe.
5
The medical record must contain:
Identifying Information
Resident Assessments
Plan of Care
Progress Notes
Diagnostic Reports
PASRR Evaluations & Results