Residents’ medical records in long-term care facilities can be voluminous. When investigating allegations by analyzing long-term care medical records, it is best to develop a system to keep information organized. It also helps to know what the most common elements of a long-term care medical record are:
- Admission Forms
- Advance Directives
- History and Physical
- Physician Orders
- Physician Progress Notes
- Nursing Progress Notes
- Assessments
- Lab Reports
- Consent Forms
- Dietary Records
- Physical/Restorative Therapy
- Social Services
- Activities of Daily Living Reports
- Flow Sheets
- Medication and Treatment Sheets
- Minimum Data Set (MDS)
- Resident Assessment Protocol (RAP)
- Preadmission Screening and Annual
- Resident Review (PASARR)
- Care Plan