Admissions are vital to a facility. They may occur daily, or even multiple times a day, and should be a part of routine operations. However, the admission process can be cumbersome, and it is easy for staff to miss things, especially if the facility receives multiple admissions in a shift. Therefore, it is important that facilities have a process in place to ensure staff complete documentation and follow up when needed.
This article will cover some of the risks incomplete post-admission medical records present and share tips the director of nursing services (DNS) can use to complete a thorough post-admission medical record review.
Negative Impacts of Omissions in the Medical Record
The medical record tells a story of how the resident is being cared for in the facility. It is a collection of history, diagnoses, treatments, and other details. To ensure the record presents an accurate story, it is important that the record contains the most complete information possible. Inaccuracies or omissions in the medical record can have many ramifications, including the following.
Resident care impacts – Omissions and inaccuracies in the medical record can hinder resident quality of care. For example:
- Omitting or incorrectly transcribing medications or treatments can lead to adverse outcomes due to incorrect dosage, missed medications, or skipped treatments.
- Undiscovered past trauma can lead to re-traumatization of the resident.
- Missing scheduled physician visits can constrain the physician’s knowledge of a resident’s recovery, which can lead to quality-of-care issues.
Survey and regulatory issues – F842 in Appendix PP of the State Operations Manual states that the facility must maintain medical records on each resident that are
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized. (CMS, 2023)
F655 requires facilities to develop and implement a baseline care plan for each resident within 48 hours of a resident’s admission and include the minimum healthcare information necessary to properly care for a resident. This information includes, but is not limited to:
- Initial goals based on admission orders
- Physician orders
- Dietary orders
- Therapy services
- Social services
- PASARR recommendation, if applicable (CMS, 2023)
Failure to maintain adequate medical records will result in a deficiency for F842 and F655, and can prompt other deficiencies as well. Depending on the issue, these additional deficiencies could result in a scope and severity of harm or even immediate jeopardy. Adverse outcomes from such deficiencies may lead to civil monetary penalties (CMPs) or denial of payment for new admissions (DPNA). Ultimately, states can terminate the facility’s license if the citation is not corrected.
Litigation – Lawsuits cost the long-term care industry millions of dollars per year. Liability can arise from issues such as pressure injuries, falls, or weight loss, if an accurate risk assessment upon admission might have prevented the harm. Even without an adverse verdict, these cases can cost facilities significant time and money, as they incur costs for things such as attorney fees and wages for staff spending time on the case.
Community impact – Inaccuracies and omissions in the medical recordcanhinder Quality Measures (QMs), which in turn affect the facility’s Five-Star rating. For instance, if a resident received an antipsychotic medication prior to admission, but the medical record does not document it or refer to it in the admission orders, when the resident restarts an antipsychotic after the MDS admission assessment, it will increase the QM Percentage of Short-Stay Residents Who Newly Received an Antipsychotic Medication. This measure, along with any change in the facility’s health inspection rating, affects the overall Five-Star rating. The Five-Star ratings appear publicly on the Care Compare website, which the public uses when choosing a nursing home for their loved ones.
Fiscal impact – Facilities with low ratings may lose referrals or contracts with organizations such as Managed Care Organizations (MCOs) and hospitals. Additionally, CMPs, DPNAs, and litigation all affect an organization’s financial stability.
A thorough review of the medical record post-admission can prevent these issues before they become a problem.
Pros and Cons of the Electronic Health Record (EHR)
EHR systems can be complicated but are often convenient. They allow staff to document quickly and create records that are easy to access. However, fast clicking can create errors. Additionally, if staff do not understand how to use the EHR system, they may make more errors, such as when entering physicians’ orders or completing assessments.
Many facilities have a hybrid medical record, with the combination of an EHR and paper documentation. This can complicate reviews, as documentation appears in multiple places. The person examining the record must collect all the documentation to ensure a thorough review.
A Comprehensive Medical Record Review
Ideally, the post-admission medical record review should occur within 48 hours of admission or re-admission. When reviewing resident records, consider the below areas:
Resident identification and legal information – This section should include at least a face sheet, guardianship/power of attorney status, preadmission screening and resident review (PASRR) recommendations, a signed admission agreement or consent to treat, and advance directives.
History and physical – Every resident’s medical record should contain a history and physical. This may come from a doctor in the community, the discharging hospital, or the facility’s attending doctor. This section may also include records from the discharging facility or a hospital giving essential background information to care for the resident.
Physician’s orders – The record must contain admitting orders, which the facility must verify to ensure accuracy. At a minimum, these orders should include the resident’s code status, medications and treatments, diet, allergies, activities, immunizations, and diagnostic tests such as labs.
Physician’s progress notes – Ensure there is an admission note present, as well as a physician’s certification for Medicare Part A if the resident is receiving skilled care.
Nursing – Facilities should complete a nursing admission assessment within hours of the admission. It should include at least the resident’s height and weight—which should be measured in the facility and not taken from previous records—as well as vital signs, any wounds present, and risk assessments such as falls, elopement, and skin.
Social services – This section should have an admission assessment completed that includes areas such as a trauma and depression screening.
Dietary – The registered dietitian should complete an admission assessment that includes wounds, calories needed, and any dietary concerns such as dialysis, swallowing difficulties, or specialty diet needs. Either the dietician or dietary manager should also address food preferences.
Activities/Life enrichment – The medical record should contain an admission assessment addressing resident preferences.
Hospice/Dialysis – If a resident is receiving hospice or dialysis services, a physician’s order should be present, as well as a collaborative care plan. If residents receive these services outside the facility, ensure that transportation is set up so they do not miss any appointments.
Baseline care plan – When reviewing the record, ensure that the baseline care plan—which must be in place within 48 hours of admission—is present and includes all the information necessary to care for the resident until completion of the comprehensive assessment and development of the comprehensive care plan.
Miscellaneous items – Each facility has its own forms and items that staff must complete upon admission. Review these to ensure completion and accuracy.
In closing, a thorough post-admission medical record review will ensure accuracy and completeness of the medical record. In turn, this will help staff provide better care to the resident. AAPACN has developed a Medical Record Audit: New Admission/Readmission tool to assist with these record reviews.
Centers for Medicare & Medicaid Services. (2023). State Operations Manual, Appendix PP – Guidance to surveyors for long term care facilities. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
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