In a nursing home, each resident is required to have a chart. The chart is the resident’s medical record and serves many important purposes:
- It contains and tracks information about the health and well-being of the resident, including key measures such as lab reports, vital signs, and the like which are the basis for well-informed medical decisions;
- It contains the resident assessments that are part of the care plan and the care plans themselves so that the staff delivering the care to the resident knows what should be done. Also, it allows the staff to track the effectiveness of the care plans as written to determine whether they need to be revised if the resident’s condition declines or the care plan is proving ineffective in practice in preventing things like falls or the development of bed sores;
- It serves as a communication tool among the staff so that nurses who take over the care of the resident know what has been happening with the resident on days or shifts previous to the one in which they are caring for the resident;
- It serves as a record of what orders have been entered for the care of the resident and what treatment and medications have been provided to the resident
- It is a record of what care and treatment have been provided to the resident and what recommendations have been made by outside health care professionals such as a wound care nurse, a speech therapist, or a nutritionist.
In a nursing home, nurses are not required to make a nursing progress note every shift. When a resident is admitted to a nursing home for rehabilitation as a Medicare admission for rehabilitation after a hospital admission, daily chart notes are required. Outside of that, nursing progress notes are only required every 30 days. In practice, they are made more frequently than that.
Besides the nursing progress notes, there are several other kinds of records which are made much more frequently than that such as Medication Administration Records and Treatment Administration Records. Nursing home charts are different from the kinds of charts that you might see from a hospital or a doctor’s office and understanding how care is delivered in a nursing home setting and how that is recorded makes it easier for experienced nursing home lawyers to understand the significance of what is in the chart – and what is missing.
Because the nursing home chart serves so many vital purposes in assuring that quality care is being provided to the resident, every nurse will agree that false charting would never be acceptable. Yet, it happens frequently – there have been a number of times where nurses have continued to chart on a resident after they have been taken to the hospital or have already died. When this happens and false charting can be established, it makes it very difficult for the nursing home to say that the records that they are relying to show that good care was provided are in fact accurate.
As more nursing homes have moved to electronic charting, one of the areas in which we see false charting more often is in “cut-and-paste” entries being made or from inaccurate selections being made from drop-down menus. With the increasing use of these kinds of medical records and the large amount of data that they create, careful analysis of the electronic nursing home chart requires diligent analysis to help show that nursing home abuse and neglect has occurred.
As experienced Chicago nursing home lawyers, we know how to analyze the nursing home chart to identify the areas in which substandard care was provided to a resident which resulted in injury to or the wrongful death of the resident. Contact us for a free, no-obligation analysis of your rights after your parent or other loved one has been injured due to poor care in a nursing home.