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What records in my loved one's nursing home chart are especially important?

A: The answer to this question varies depending upon the specific facts of your case. However, the following documents are generally important.

IMPORTANT DOCUMENTS: Initial Review of Nursing Home Case

  • Admission sheets, contracts, and related documents;
  • Transfer sheets, e. g. , nursing home, ambulance, hospital;
  • Hospital discharge summary (if any);
  • Physicians' orders;
  • Physicians' progress notes;
  • Records documenting communication with physicians;
  • Nursing admission assessment and monthly and other summaries;
  • Discharge plans;
  • All care plans;
  • Nursing notes;
  • Decubitus ulcer/pressure sore and/or skin reports;
  • Medications sheets, treatment sheets, graphic sheets, I&O records, CNA flow sheets, ADL sheets, and any other CNA records;
  • Chronological drug reviews;
  • Nutritional assessments and notes along with weight records;
  • Lab and x-ray reports;
  • Restorative programs and notes;
  • Activity records;
  • Social service records;
  • Physical therapy records;
  • Occupational therapy records;
  • Speech therapy records;
  • Permits and releases;
  • Duplications of photographs;
  • Correspondence to and/or from the resident and/or family;
  • Initial Service Plan/Care Plan;
  • Minimum Data Set - initial and subsequent summaries;
  • Resident assessment protocol summaries;
  • Resident assessment protocol;
  • Itemized copy of the bill for treatment and services rendered to date and submitted in the patient's name for the duration of the resident's stay; and

Any and all incident/occurrence reports that in any way relate to the resident.

2810 Gilman Drive
Plover, WI 54467
phone: 715.343.2850
toll free: 855.343.2850
fax: 715.343.2803
email: jason@studinskilaw.com
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