Medical Records Policies And Procedures For Assisted Living
Medical Records Policies and Procedures for Assisted Living Facilities
As mandated by law, healthcare facilities, including assisted living facilities, are required to maintain comprehensive medical records for each patient they treat (Pozgar, 2004). These records serve multiple purposes, including continuity of care, legal documentation, and compliance with healthcare regulations. Given the importance of accurate and secure record-keeping, it is essential for facilities to establish clear policies governing the maintenance and release of medical records.
This document presents a two-part comprehensive policy for medical records within an assisted living facility. Part I focuses on the maintenance and documentation practices, while Part II addresses record ownership, confidentiality, and procedures for record release.
Part I: Policy on Maintenance of Medical Records
Contents of Medical Records
The medical record for each resident shall contain all pertinent information related to their health and healthcare provided during their stay at the facility. This includes, but is not limited to:
- Personal identification information (full name, date of birth, emergency contacts)
- Medical history and current health status
- Medication and treatment records
- Progress notes and nursing assessments
- Physician orders and care plans
- Laboratory and diagnostic test results
- Consent forms and advanced directives
- Immunization records
- Discharge summaries and referral documentation
Guidelines for Entry and Corrections
All entries within the medical record shall be made promptly, accurately, and clearly to ensure the integrity of the record. Entries must be legible, dated, and signed by the healthcare professional making the entry, including their credentials.
In the event of an error or correction, the original entry shall not be obliterated or erased. Instead, a single line shall be drawn through the incorrect information, which must then be initialed and dated by the healthcare professional. The corrected information shall be entered alongside or beneath, with an explanation if necessary, to preserve the record’s chronological integrity.
Security and Storage
Medical records shall be stored in a secure, access-controlled environment, ensuring protection against unauthorized access, loss, or damage. Electronic records should be protected with password controls, encryption, and regular backup. Paper records shall be kept in locked cabinets, accessible only to authorized personnel.
Retention Period
Records shall be retained for the period mandated by state law, which typically ranges from five to seven years after the resident’s discharge or death. The facility shall ensure proper disposal of records upon reaching the end of their retention period, in accordance with applicable regulations and confidentiality standards.
Part II: Policy on Record Ownership, Confidentiality, and Release
Ownership of Medical Records
Legal ownership of medical records shall remain with the healthcare facility. However, the resident, or their legally authorized representative, shall have the right to access the record in accordance with applicable laws. The record constitutes the property of the facility but serves as a legal document of the resident’s health history.
Procedures for Releasing Records
Requests for medical records shall be made in writing and authorized by the resident or their legal representative. The facility shall verify the request’s legitimacy before releasing any information. Records will be provided within the timeframe specified by law, typically within 30 days.
Releases may be made in person, by mail, or via secure electronic transfer, as appropriate. A fee to cover copying and mailing costs may be charged in accordance with state regulations.
Maintaining Confidentiality and Law Compliance
Protection of resident confidentiality is paramount. All staff handling medical records shall receive training on confidentiality requirements and legal obligations set forth by laws such as the Health Insurance Portability and Accountability Act (HIPAA). Electronic records shall be protected through encryption, secure login credentials, and audit trails.
Any breach of confidentiality must be reported immediately, and appropriate measures will be taken, including notifying affected residents if required by law. The facility shall regularly review its policies and procedures to ensure compliance with current laws and standards governing medical record confidentiality and privacy.
Conclusion
Establishing robust policies for the maintenance and release of medical records is essential in an assisted living facility to ensure legal compliance, protect resident confidentiality, and facilitate quality care. By standardizing documentation procedures, securing records, and managing access appropriately, the facility can uphold its legal and ethical obligations to residents and staff alike.
References
- Pozgar, G. (2004). Legal aspects of health care administration (9th ed.). Sudbury, MA: Jones and Bartlett.
- American Health Information Management Association (AHIMA). (2019). Standards for the management of health records.
- U.S. Department of Health and Human Services (HHS). (2013). Summary of the HIPAA privacy rule.
- Centers for Medicare & Medicaid Services (CMS). (2020). Guidelines for record retention and management.
- National Committee on Quality Assurance (NCQA). (2021). Health record confidentiality standards.
- State laws governing medical records retention and confidentiality. (Various state statutes)
- Joint Commission. (2022). Standards for medical record management.
- Office for Civil Rights (OCR). (2022). Guidelines for breach notification and confidentiality.
- American Medical Association (AMA). (2020). Guidelines for medical record documentation.
- Healthcare Information and Management Systems Society (HIMSS). (2021). Secure health data management practices.