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Understanding Medical Records

Ask for the records if you have concerns about medications, mobility, dehydration, malnutrition or falls. As a family member and the resident’s advocate, you have a right to see the records.

Here are the parts of the record to focus on:

Orders

Physicians have the responsibility and authority to order medication and services for the resident. You can check these orders to see what medication or services or consult have been ordered. The order should have a time and date and should be legible. It should also have some indication that the R.N. acknowledges receipt and review of the order and that it has been carried out.

Progress Notes by Doctors

There is another section of the medical record that includes entries by doctors and nurses, and sometimes others, about the resident. This section is like of log. Most doctors were trained to write their notes in a SOAP format. This means that they first section should detail the subjective concerns of the resident/family advocate. The objective section follows this. Here is where the physician does an examination of the patient, usually going through each system of the body and recording at least the important abnormal findings. The third section is assessment, which is the where the doctor records his or her thoughts about what is going on the with the patient after considering the subjective complaints and the findings on physical examination along with any test results or images. The final section is the Plan. Here, the doctor writes out the plan of action which should address the concerning findings and include a plan for physician or other follow up.

Nursing Notes

In some facilities the nurses also write in the progress notes. In other facilities, the nurses have their own special forms where they record their nursing assessments and interventions from their shift. There will also be other specialized forms for medication (MAR) and for treatment (TAR).

You need to check the skin sheet to verify if the resident is being turned and the skin integrity is being checked. However, you also need to check yourself. It is key not to let any concerning new “hot spots” progress. If you see a red spot or a pressure point that is concerning you need to ask questions and act on it right away.

Also look at the weight chart. A resident’s weight loss can be a red flag for dehydration or other concerning medical problems.

If a resident has a fall or any other abnormal event the facts and circumstances should be documented in the chart along with a plan. In most cases, a fall in an elderly resident requires physician assessment.

Laboratory Reports

The lab report can also give you clues to problems that need to be addressed. A high white blood count (WBC) can be a sign of an infection. The lab gives you the normal range so that you can compare the resident’s value to the normal population.

If you have question or want more information please call 202-803-5800 or email us to learn more.

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