Strategies for Accurately Completing Residents' Medical Records

The accuracy of a long-term care facility's medical records system requires effective training, ongoing education, and great communication among the staff that handle the records. Staff need to be constantly aware of issues that could impinge on that accuracy and have strategies in place to ensure they have adequate time to document all events that occur-from a fall to a prescription drug reaction to weight gain or loss.

Some of the issues that may prevent accurate documentation include:

Staffing shortages. A facility must have an adequate resident to nursing staff ratio in order to operate effectively. When staff is short, the nurses and aides left to take care of the residents often do not have adequate time to accurately complete a resident's medical record or file an incident report.

How Documentation Helps Mitigate Risk in Long-Term Care Facilities

Accurately documenting and completing health records is essential for a long-term care facility to minimize risk and liability. Written documentation supports and validates the actual events that took place during a resident's care or during an incident involving a resident. Should an incident occur-such as a fall-or a resident becomes gravely ill, accurate documentation of events would be needed as evidence if the family or resident file a lawsuit.

For that reason, it is imperative to document the event on the resident's chart and follow the facility's incident reporting procedures. Completing both the medical record and incident report are important to supporting the defense of the facility if an incident is under investigation or goes into litigation.

Some examples include: