LTC Health Information Practice & Documentation Guidelines
Version 1.0
September 2001

Table of Contents



A medical record must be maintained for every resident in a long term care facility. With varying levels of automation, there may be some records maintained electronically and some in paper format. This section of the report will deal with maintenance of the paper medical record.

It is critical that every facility have formalized systems in place for the maintenance of their records. Records should be systematically organized and readily accessible. The following practice guidelines establish a baseline for the systems that should be in place for maintaining the record systems in a facility.

4.1.1 Maintaining a Unit Record

A unit record and unit numbering system is recommended for long term care facilities. With a unit record, the patient is assigned a medical record number on the first admission which is retained for all subsequent admissions/readmissions. The patient’s entire medical record is thus filed together as a unit under one number (there may be multiple volumes and folders). (Health Information Management, Huffman)

In long term care, the record from previous admissions should be brought forward to be filed with the current admission. All records from previous admissions are pulled forward and usually maintained in the overflow files. It is best to separate the past records for a current admission from the discharge record files so the chart is not inadvertently filed in storage and destroyed.

Bringing previous charts forward will provide the most comprehensive picture of the residents medical history and therapy. The previous records should be readily accessible to staff for use in the assessment and care planning process.

The medical records from previous stays remain in their original file folder and are retained chronologically with other records for patients currently admitted to the facility. The records from one discharge to another are not combined into one folder.

4.1.2 Assigning a Medical Record Number


  • The healthcare organization has a policy that requires a separate, unique health record for each resident.
  • Each resident admitted to the long term care facility should be assigned a unique medical record number. The following are general rules to follow when assigning medical record numbers:

    • Assign a medical record number only after a resident is admitted. This will prevent numbers from being assigned when the resident is not actually admitted to the facility.
    • Assign numbers chronologically. Each new admission is assigned the next sequential number.
    • Exception: For any subsequent admissions, reassign the previous medical record number. You may use a modifier to the medical record number to designate multiple admissions. For example: 1234 – a or 1234 – Always verify in the master patient index that the resident had not been in the facility before.
    • If a resident was assigned a number, but was not admitted, make a notation in the admission/discharge register that the resident was not admitted.

    4.1.3 Maintaining Records in a Continuum of Care:

    For healthcare campuses or continuums it is recommended that separate records are kept for each of the different care settings. For example, a separate record is maintained for assisted living, a record for the NF/SNF, a record for home care, etc. However, it is not recommended to create different records for a change in level of care such as from NF to SNF.

    When transferring between care settings (i.e. assisted living to SNF), it is recommended that an interdisciplinary transfer form or discharge instructions be completed to assure continuity of care. Include copies of relevant documentation to facilitate the assessment and care planning process.

    Health information staff should oversee record management, storage, retention, and destruction for the medical records maintained by the campus to assure that the medical records for each of the care settings are maintained in an organized and systematic filing and retrieval system.

    To assist with tracking medical record numbers/campus numbers, admissions, discharges and transfers there should be a campus-wide master patient index maintained or another mechanism to link all records to the resident.

    4.1.4 Defining What is Part of the Medical Record

    The medical record in a long term care facility reflects the multi-disciplinary approach to assessment, care planning and care delivery. The medical record includes but is not limited to the following type of information: Resident identification, admission/readmission documentation, advance directives and consents, history and physical exams and other related hospital records, assessments, MDS, care plan, physicians orders, physician and professional consult progress notes, nursing documentation/progress notes, medication and treatment records, reports from lab, x-rays and other diagnostic tests, rehabilitation and restorative therapy records, social service documentation, activity documentation, nutrition services documentation, and other miscellaneous records including correspondence and administrative documents.

    Facility policy should specifically outline in the format of a chart order the exact documents and records that will be considered part of the medical record. If portions of the record will be retained in an electronic medical record system, policies should differentiate between those records that will be paper-based and those that are electronic.

    4.1.5 Maintenance of the Medical Record

    It is critical that both the active record and the overflow records are maintained in a systematically organized fashion. This means that all records have an established chart order or order of filing that is followed. All records (records on the nursing station, overflow records, and discharge records) should be readily accessible, maintained in an organized chart order, filed in an easily retrievable manner, and maintained in folders or chart holders sufficient in size for the volume of the record. The chart holders and folders should be kept neat, clean and orderly.

    It is recommended that a chart order or order of filing with thinning guidelines be kept in the record and at the nursing station to direct staff to the proper location of forms.

    4.1.6 Identification (Name and Number) on pages of the Medical Record

    From a legal perspective, each page or individual documents (i.e shingled telephone orders) in the medical record should contain resident identification information. At a minimum, both the resident name and medical record number should be on each form. If labels/label paper is used, resident identification information must be included on the label. The name and number should be placed on both sides of a page because records are frequently copied and both sides may not be included. The name of the form should also be printed on both sides of a two-sided form.

    For example, identification information can be written on the page in permanent ink, stamped using an addressograph, or affixed with a label placed. Resident specific information printed from a computer system to be filed in the medical record should include resident identification information on each page.

    4.1.7 Common Forms and Thinning Guidelines

  • The healthcare organization has a policy that establishes a uniform chart order for health records.
  • This section outlines the common chart forms found in a long term care record. The titles, location in the record may be different, but the thinning guideline would remain consistent for the type of documentation contained. Thinning the medical record is a process of removing records older than a certain date and moving them into a secondary record known as the overflow record.

    The establishment of thinning guidelines is a standard of practice for the long term care industry. Federal regulations require clinical records to include (1) sufficient information to identify the resident; (2) a record of the resident’s assessment; (3) the plan of care and services provided; (4) the results of any pre-admission screening conducted by the State; and (5) progress notes. 42 C.F.R. § 483.75 (l)(5). Check licensure rules to determine if state law delineates a specific thinning guideline.

    The goal of the thinning guideline is to retain documentation in the resident’s chart that reflects the current plan of care and services provided. Unless required by state regulations, it is not necessary to keep the original assessment or progress notes in the record. The overflow record should be easily accessible for review of admission documentation.

    By listing a form in the following chart order, we are identifying documents commonly found in the medical record. This should not be interpreted as a recommendation or requirement that the form be a mandatory part of the long term care record. See section 6.0 on content of documentation to address the type of documentation and the associated regulatory reference.

    Identification and Admission Documentation  
    Admission Record/Facesheet Current Facesheet

    Pre-admission Screening (PASARR)

    Preadmission Assessment/Intake 3 months after admission
    Admission Consent Permanent Financial/Administrative file
    Admission Agreement Permanent
    History and Physical and Hospital Records  
    H&P Most
    Hospital Discharge Summary Most Current
    Hospital Transfer Form Last Hospital Stay

    Other Hospital Records(All hospital records received should be retained)

    Retain pertinent records for 3 months after hospitalization then thin.

    Immunization Records Permanent
    Advance Directives/Legal Documents  
    CPR Directive Most Current
    Resident Self Determination Act Acknowledgement. Most Current
    Living will Most Current
    Advance Directive Most Current
    Durable Power of Attorney Most Current
    Guardianship/Conservator Most Current
    Legal incapacitation Most Current
    Consents, Acknowledgements (For example, Physical Restraints Consent, Admission Consents,
    Consent to Treat, Consent to Photograph, MDS Consent, MDS Acknowledgement, Release of Information Consent, Release of Responsibility/Leave of Absence)
    Most Current
    Clinical Assessments (At a minimum, retain most recent assessment plus one previous)  
    Nursing Assessment 6 months to 1 year
    Wound and Skin Assessments 6 months to 1 year
    Fall Assessment 6 months to 1 year

    Bowel and Bladder Assessment

    6 months to 1 year

    Pain Assessment

    6 months to 1 year
    Mini-Mental/Cognitive Exam 6 months to 1 year
    Restraint Assessment 6 months to 1 year
    Minimum Data Set and Care Plan  
    MDS 15 months readily available
    Care plan Current care plan
    Specialty Care Plans ie: hospice/dialysis Current plan
    Care Plan Signature Records (if used) Current plan
    Care plan recap (if used) Current plan
    Physicians Orders  
    Computerized Recaps or Renewals 3 months
    Telephone Orders 3 months
    Interim orders 3 months
    Protocols or Standing Order Policies (if used) Current
    Fax Orders 3 months
    Physician and Professional Progress Notes/Consults  
    Physician Progress Notes 1 year
    Cumulative Problem/Diagnosis List Most recent
    Annual Exams Most recent
    Other specialists/consultation 1 year
    Dental Progress Notes/Exams 1 year
    Podiatry Progress Notes/Exams 1 year
    Psychological Evaluation Current
    Nursing Notes/InterDisciplinary Notes  
    Nursing Notes 3 months

    Interdisciplinary Notes

    6 months
    Nursing Summary Forms/Flowsheets 3 months
    Medication, Treatment and Other Flowsheets  
    Monthly Medication and Treatment Records 3 months
    Vitals Sign Record 1 year
    Weights Record 1 year
    Intake and Output Records 3 months
    Behavior Monitoring Records 3 months
    Other Flow Sheets (Diabetic site rotation, etc) 3 months
    Pharmacist/Drug Reviews Recommendations 1 year
    Lab, X Rays, and Special Reports  
    Lab Reports (frequently ordered) 3 months
    Annual or interim Lab Reports 1 year
    X-Ray Reports 1 year
    Special Diagnostic Tests 1 year
    Rehabilitative Therapy (PT, OT, SLP)  
    Therapy Evaluation Most Recent
    Therapy Certificatio/Recertification 3 months
    Progress Notes 3 months
    Discharge Summary Most Recent
    Therapy Screen Most Recent
    *Once therapy is discharged thin therapy information for that discipline except the evaluation and discharge summary.  
    Rehab Nursing  
    Screen Most Recent
    Rehab Nursing Assessment Most Recent
    Progress Notes/Treatment Records 3 months
    Social Service, Dietary (Nutrition Services), and Activities (Therapeutic Recreation)  
    History Permanent
    Progress notes 6 months to 1 year
    Assessments Most Recent
    Clothing list or Inventory List (If required) Most Current

    *Common Chart Forms – The chart forms and location are not meant to represent a recommended chart order or forms. Chart order and the types of forms used are facility-specific. The forms named represent common types of documentation found in a long term care record.

    ** Thinning Guidelines – These guidelines are recommendations and provide a baseline. Each facility should adapt and develop thinning guidelines that meet the needs of their resident population and staff needs. Integrating Hospital Documents into the Long Term Care Record

    Hospital or another healthcare providers (i.e. another LTC facility) records that are sent with a resident to provide information for continued care and treatment should be retained by the facility. It is recommended that pertinent information such as the history and physical, discharge summary, and transfer form be kept in the medical record. All other records sent (copies of progress notes, labs, consults, etc.) should be kept for 3 months in the record to provide information when establishing the current plan of care and treatment and then thinned and retained in the resident’s overflow record. The records provided on admission, readmission, or return from the hospital should never be destroyed. See section x of this report for guidance on how to handle release of information or redisclosure of hospital and other healthcare provider documents.

    A copy of the history and physical from the hospital is commonly accepted as the history and physical on admission to a LTC facility. When necessary, physicians are expected to update the H&P or to write a progress note that documents the resident’s current condition on admission.

    4.1.8 Thinning the Medical Record

    Each facility should develop a schedule for thinning the medical records. It is generally recommended that records are thinned quarterly and as needed schedule. Using the MDS/care conference schedule and thinning after the care conference can provide calendar for checking the chart to determine if thinning is needed.

    Once the record has been thinned a notation should be made in the record. For example, a label can be placed in the inside cover of the chart that states the date the record was thinned. The records thinned from the chart should be filed in the overflow record immediately to assure that resident records are always accessible and easily retreivable.

    4.1.9 Maintaining the Overflow Record of Thinned Documents

    The overflow record is considered part of the resident’s active medical record. The overflow records which contain the documentation thinned from the chart must be systematically organized (a chart order should be established) and readily accessible. Because it is not always possible to keep all documentation in the chart holder at the nursing station, the thinned information is generally kept in the HIM department.

    Standards for maintaining the overflow medical record:


    • For ease in locating documents a chart order should be developed for overflow records. It is recommended that the overflow chart order be the same as the discharge chart order to facilitate quick assembly upon discharge. All like forms should be filed together (i.e. all nurses notes together in date order). Use index tabs if desired to indicate the sections of the chart (index tabs from an office supply company work well in thin charts). Tabs will make retrieval and filing of documents easier.
    • Records should be maintained in date order. Facility policies should define if forms will be filed in chronological or reverse chronological order. Filing in chronological order is considered the gold standard, but reverse chronological would be acceptable defined in facility policy and consistently applied to all overflow records.


    • Overflow records should be filed in a location that is secure and readily accessible.
    • When overflow records are removed a chart locator or tracking system must be used to identify the individual removing the chart, the date, and the location.

    4.1.10 Maintaining a "Soft Chart" or "Shadow Record" and Other Types of Records:

    Soft charts are resident-specific records that are maintained by a discipline that contains extra notes, observations and copies of documentation kept in the medical record. The record is not usually integrated with the resident’s legal medical record. The soft chart is often a working duplicate of the medical record.

    Soft charts are generally not recommended. The facility has legal risks because this type of record is discoverable in a legal process and could contain contradictory or damaging information. There is potentially a loss of critical information that should be documented in the medical record, but it is not.

    If facility administration approves the use of soft charts, policies should be developed to manage the records with the same structure and organization as the resident’s legal medical record. The following systems should be developed for each type of soft chart:

    • Implement systems to assure that the records are physically secure such as retaining information in locked file cabinets with access by limited staff.
    • Policies should be developed to handle the confidentiality of information and documents contained in the record.
    • Records should be identified on the retention and destruction schedules.

    Social Service and Financial Files:

    Both social service and financial files are commonly maintained by long term care facilities. Both of these type of records are acceptable. They contain information that is highly sensitive and often not related to resident care. Policies must be developed to define what information is retained in each type of record. There is a risk with a social service file that information which should be documented in the medical record is kept only in the social service record. Along with guidelines to define what is contained in the file, policies should define security, confidentiality, retention and destruction.

    Communication Records/Shift Worksheets:

    Communication and Shift Records are a common form of communication between nursing staff working on different shifts. They usually contain multiple residents on one page and are not considered a formal part of the medical record. These records are acceptable but standards should be in place to assure that the medical record also reflects the resident’s condition, nursing observations, and assessment that are often found in the communication records. It is critical that the medical record contain the same information as the worksheets on condition, observation and assessments.

    Facility policy should establish retention and destruction procedures. Determine where the reports will be stored, how they will be collected, how long they will be retained, and when they will be destroyed. In absence of a state law, it is recommended that shift reports be retained for 30 days and then destroyed.

    Outpatient Records and Records Maintained by Vendors:

    When vendors such as a therapy provider is contracted with a facility, it is acceptable for a the company to maintain their own medical record. The facility must ensure that the vendor providing outpatient services through the facility has appropriate policies in place to deal with security, confidentiality, retention and destruction.

    If facility staff is providing outpatient services, the facility must develop and manage the record systems and procedures to assure security, confidentiality, retention and destruction. If the facility employs the therapists, it is not recommended that they have a separate therapy chart (soft chart). All documentation should be maintained in the medical record.

    4.1.11 Forms Control Processes

  • A procedure has been established to address issues related to the completion of all health record forms and data entry screens.
  • A process should be in place to review and approve new or revised forms. There should be a formal process such as a forms committee to carry out the following functions:

    • Forms should be titled and indexed. A master of each form should be maintained.
    • Review and approve new forms. New forms should be reviewed for content, potential duplication of information already being documented, and inclusion of basic identification information: Title of form, resident name, medical record number, page numbers ( page x of y) if applicable, form control number if applicable, and revision date.
    • Review and approve revisions to forms.
    • Identify forms which should be deleted or inactivated and assure that the form is no longer available for use.


    The content, completion, timeliness and accuracy of medical record documentation is extremely important in a long term care facility. Documentation has a far-reaching effect on most aspects of the organization’s operation. The quality and type of care and services delivered to the resident are determined in part through documentation. On-going planning and assessment rely heavily on the quality and accuracy of the documentation in the chart. The medical record is also used to determine survey compliance, reimbursement, and serve as a source document for legal proceedings.

    Proactive (concurrent) monitoring of the completion, timeliness and accuracy of the medical record documentation is critical. Both the need for good documentation and risk factors hindering quality support the importance of on-going, scheduled audits and monitoring for every resident’s medical record.

    4.2.1 Qualitative vs. Quantitative Audits and Monitoring

    There are two broad types of audits – qualitative and quantitative. Qualitative audits look at the quality of documentation assessing adherence to clinical practice guidelines, evaluating consistency in charting, and adherence to regulations, standards and interpretations. This type of audit is usually completed by a staff member or consultant who has professional training, education or experience. Qualitative audits are more subjective than quantitative. The auditor tries to determine if the proper care was delivered based on the documentation.

    Facility staff can be trained to complete quantitative audits which focus on whether a document is complete (all sections of a form), authenticated, or timely rather than what the documentation states. A training process is necessary to help staff understand what they are to look for and why. This type of audit is more objective than a qualitative audit. Staff can usually determine if an audit element is in place or not (similar to a yes – no question).

    On an on-going basis, facilities should have quantitative monitoring in place to assure complete and timely records. Admission, concurrent and discharge record monitoring assures that analysis is completed throughout the residents stay. The goal to continuous monitoring throughout a residents stay is to identify problems or omissions when correction is possible. Analyzing the record on discharge makes it virtually impossible to legally and ethically address or correct most documentation problems or ommissions. For example, if an assessment is not completed on admission nothing can be done on discharge, but if it is found during an admission audit the assessment can still be completed in order for the facility to provide appropriate care and services for the resident.

    4.2.2 Assessing the Quality of Documentation

    When completing a qualitative audit, the reviewer should have the ability to assess the following issues, identify strengths and weaknesses, and provide suggestions to correct future documentation discrepancies.

    • Consistency in documentation between progress notes, assessments, care plans, etc.
    • Duplication or redundancy in documentation.
    • Contradiction in documentation without a clear reason for the differences. This may occur between two disciplines or within one discipline such as nursing where multiple staff members chart on a similar issue.
    • Documentation that is missing key elements for the proper assessment or planning of a problem.
    • Documentation reflects application of appropriate practice guidelines, standards, regulations, reimbursement rules, and clinical protocols across all disciplines.
    • Understanding of the reason for all types of documentation in a long term care record and the underlying guidelines, standards, regulations, or clinical practice protocols.

    A health information consultant should have the ability to provide a qualitative analysis of the documentation and content of the medical record and provide feedback and suggestions for problems identified.

    4.2.3 Routine Audits/Monitoring (Criteria and Timeframes)

    Every long term care facility should have systems in place for monitoring completion of their documentation on an on-going basis. At a minimum, records should be reviewed on admission and hospital return, concurrently on a quarterly basis, and upon discharge/death.Not all audit findings will be correctable. For findings that cannot be corrected, the information should be gathered for training/retraining, system evaluation and improvement.

    The criteria in the following table can be used to develop and tailor audit and monitoring tools.

    Every long term care facility should have systems in place for monitoring completion of their documentation on an on-going basis. At a minimum, records should be reviewed on admission and hospital return, concurrently on a quarterly basis, and upon discharge/death.

    The criteria in the following table can be used to develop and tailor audit and monitoring tools.

    Quantitative Monitoring Criteria

    Admit/Return first 24 to 48 hours

    • Transfer form or order to admit received.
    • Admission orders transcribed accurately from transfer form.’
    • All orders required per facility policy are verified or clarified by the attending physician notified.
    • If transfer form not signed by physician, orders are verified by telephone or fax order.
    • A diagnosis or reason is identified for each medication, ancillary service, treatment with billable supplies that are ordered. (Diagnosis in text of order, on diagnosis list, or through supporting physician documentation).
    • Admission orders are signed and noted by a nurse as appropriate in accordance with facility procedure.
    • Orders are transcribed accurately to MAR and TAR.
    • All medication orders include the name of the med, dose, frequency, route, and if appropriate the duration. PRN orders should include reasons for administration.
    • An initial care plan is implemented including diet and nursing care.
    • Admission note is completed including time of admission, how resident was admitted, and condition of resident.
    • Initial Medicare Certification is completed if applicable.
    • Allergies are identified.
    • Discharge plan is initiated if applicable (i.e. as required by Joint Commission Accreditation
    • Face sheet or demographic information on record.
    • H&P and Discharge summary requested from hospital if applicable and if not sent with resident.
    • If H&P not completed prior to admission, an exam is scheduled per state requirements.
    • Advanced directive acknowledgement is completed. A copy of the directive is in the record if applicable, physician orders coincide with resident directives.
    • Inventory of personal effects is completed if applicable.
    • Nursing Assessments and others required per facility policy are completed immediately upon admission are complete, timely and authenticated (e.g. skin assessment, fall assessment, etc.). (No missed sections or questions on the assessment without explanation).
    • Admission vital signs, height, and weight are documented.
    • Admission paperwork such as admission consents including the consent for use of protected health information, bill of rights acknowledgement, advanced directive acknowledgement, etc. Are completed per facility policy.
    • PASARR documentation on record or review scheduled.
    • Admission PPD read or TB test ordered. If not, documentation indicates if contraindicated or previously completed within an acceptable timeframe.
    • Although it is not recommended to accept an order for restraints on admission, if physical restraints are ordered upon admission the order should include the type of physical restraint/device, the reason for use, the frequency of use and the restrictions for use. An initial assessment should have been completed for the use of the restraint. Informed consent has been obtained from the resident or their representative.
    • Diagnosis list has been started and ICD-9-CM codes assigned.
    • Labs, x-rays, consultation visits, etc. that were ordered upon admission have been scheduled.
    • Assessments and monitoring records were initiated or completed per facility policy: Common forms include skin risk, fall risk, bowel & bladder monitoring, intake and output records, self-administration of meds, pain assessments, interdisciplinary assessments (dietary, activities, social service, chaplain), teaching/resident education plans, oral/dental assessment, restorative nursing assessments.
    • If therapy has been ordered, the therapy plan of treatment/evaluation has been initiated no later than 48 hours. Physician orders have been clarified to include the specific therapy plan.

    Admit/Return 14-21 days

    • The assessments listed in the 24-48 hour audit that were not initiated in that time frame should be audited during the 14-21 day audit.
    • Items that were not complete on the admit and 24-48 hour audits are checked.
    • 14 day Medicare Recertification has been completed if applicable.
    • The 2nd step of the PPD/TB test was administered and read (if applicable).
    • The MDSs (both OBRA/regulatory and PPS if applicable). See the MDS audit criteria for specifics.
    • Care plan is complete by day 21 (should be available for use by day 21)

    RAI Process

    The RAI process should be audited by someone independent of the process to assure compliance with completion and timeliness timeframes. Recommend auditing each MDS (OBRA/Regulatory and PPS).

    • Basic tracking form complete and signed.
    • All questions on the MDS are appropriately answered.
    • On admission, MDS Face Sheet completed, signed and dated.
    • A-3 Assessment Reference date within the proper range.
    • R2b date and dates of staff completing the MDS are not prior to the A-3 date. Staff dates cannot be after the R2b date.
    • Staff signatures include their title, sections completed and date completed.
    • Triggered RAPs are identified in section V.
    • For RAPs triggered, assessment documentation is shown in the location of information column.
    • Date in VB2 is no later than day 14 after the start of the assessment period. (Admission no later than day 14, quarterly no more than 92 days between R2b dates, and annual no more than 366 days from last annual VB2 date).
    • Date in VB3 is no more than 7 days after VB2.
    • RAP documentation/assessments are completed prior to Vb2.
    • If a RAP is identified to be care planned, the issue is addressed on the residents plan of care.
    • Readmission/Return and Discharge Tracking forms are completed within 7 days of the event.
    • Significant change assessment completed within 14 days after significant change in status is noted.
    • Corrected MDS documents are called to the attention of the business office to assure that adjustment bills are completed if necessary.

    MDS Validation Reports

    • The validation report is reviewed after each submission and appropriate follow-up is conducted to address errors.

    Concurrent or Quarterly

    • Admission Record/Face Sheet: Check if any changes have been made on the face sheet page or any areas are inaccurate. Reprint a new face sheet if there are changes or inaccuracies.
    • Diagnosis list updated and coded: Check if new diagnoses have been written on the diagnosis list. Check physicians orders, progress notes, referrals, etc. to see if the physician has documented any new diagnoses. Code new diagnoses, input into the computer, and print a new list.
    • RAI Process: See RAI Audit Criteria
    • Care Plan Current and Complete: Care conference held within 7 days of the MDS (either quarterly or full). All those in attendance signed the attendance record. Care plan is rewritten or reprinted if there are too many changes and it is difficult to read/use.
    • Nursing Assessment and Monitoring: Assessments completed per policy. All entries are signed and dated. Monitoring records are completed and authenticated – no open holes or breaks in documentation.
    • Restorative Program (if applicable): actual treatment time is documented for rehab nursing service delivery record, an assessment has been completed. Progress notes reflect residents status and progress. The care plan reflects restorative program and goals.
    • Nursing Documentation: Nurses notes are signed and dated. Follow-up charting complete for incidents/falls. Medicare charting completed when applicable Weekly/monthly summary or case mix charting completed as applicable.
    • Physician Orders – Renewals: Physician has signed and dated the renewals in the specified timeframe. Orders did not expire before being resigned. Nursing noted orders upon return per facility policy.
    • Telephone and Fax Orders: All telephone orders (TO's) are complete, signed and dated. All original telephone orders have been returned within the appropriate time frame. All orders given by a physician has a corresponding signed order (TO, fax order, signed physician referral, etc.).
    • Physical Restraints: If ordered, current assessment completed, informed consent documented, order matches device in use. Documentation includes alternatives tried before restraint used and the symptom being treated..
    • Psychotropic, Antipsychotic, Hypnotic medication Monitoring: If ordered, monitoring assessments completed, signed and authenticated. Side effect monitoring completed. Dose reduction documentation or justification on record.
    • Physician Visits: Visits are made timely. Progress notes written or dictated notes sent back and filed. Notes are authenticated and dated. Required NP/PA and physician visits alternate.
    • Physician referrals are complete and noted by the nurse receiving. Orders on physician referral have been verified with the attending if appropriate and transcribed accurately.
    • Documentation of consults for dental, vision, podiatry, audiology/hearing aid, hospice, and psychological services are in record when applicable.
    • Vital Sign Records: Vitals completed and recorded in a timeframe consistent with facility policy and state regulation where applicable.
    • Weights recorded monthly or per facility policy/state regulation where applicable. Changes in weight (5% in 30 days/10% in 6 mo.) noted in record for possible significant change assessment.
    • Medication and Treatment Record (MAR/TAR): Look for open holes on the MAR/TARs. PRN records signed, reason and result documented. Other flowsheets are complete.
      All flowsheets and MAR/TARs have resident name, MR#, month and year identified on every page.
    • Pharmacist review conducted monthly.
    • Medication disposal/destruction records are complete. Documentation signed and dated.
    • Labs: All orders for labs (routine and stat) have a corresponding lab report in chart. Labs are noted and dated by nursing. Lab results are communicated to physician.
    • Social Service Documentation: Each quarter a progress note or assessment form is completed at the time of care conference noting changes to be made to the care plan. Updates are completed on the Social History. Entries on all documentation are signed and dated.
    • Dietary/Nutrition Documentation: Each quarter a progress note or assessment form is completed at the time of care conference noting changes to be made to the care plan. Intake monitoring records are completed as appropriate. All entries are signed and dated.
    • Activity Documentation: Each quarter a progress note or assessment form is completed at the time of care conference noting changes to be made to the care plan. All entries are signed and dated.
    • Rehabilitation Documentation (PT, OT, SLP): Documentation for each therapy is filed together (all PT doc. together, etc.) For residents currently treated, service delivery record are completed, treatment time documented, signed and dated, progress notes are written at least every seven days, the physician plan of care/evaluation/cert/recert has been completed and signed by the therapist and physician. A current physician order is on record matching the current treatment plan.
    • Chart Thinned: The chart is thinned per thinning schedule. Forms are repaired. Chart is cleaned and organized.

    Discharge Analysis

    • Chart is placed in discharge chart order per facility policy.
    • All Forms have Name/MR#.
    • Discharge Plan of Care or Discharge Instructions or Transfer Form: All sections are completed, signed and dated by appropriate discipline(s) Resident received a copy of discharge plan/instructions which has been written in layman’s terms.
    • Recap of stay documented for planned discharged.
    • Physician Discharge Summary completed if required by State law. Initiated by facility staff. Physician completed, signed and returned within 30 days of discharge unless other time frame required by State law.
    • Discharge Order: Discharge order obtained for the day of discharge Order included discharge destination, if meds sent when transferring to another facility include statement in order. Order upon death states to release the body or documentation of physician notification on record. Discharge order has been signed, dated and returned by the physician
    • Orders: Renewals / Telephone Orders (TO's): All renewals have been returned and signed All TO's have been returned and signed. Facility policy should define how to handle orders that have not been returned.
    • Discharge documentation: There is documentation of events leading to discharge or death: Nurse wrote a note reflecting date and time of discharge, the resident's disposition, condition of the resident at discharge, where discharged to, and the individual taking responsibility for the resident.
    • Disposition of medications documented per facility policy.
    • Disposition of personal belongings: Inventory of Personal Belongings completed on discharge; or documentation of belongings sent with resident or picked up by the family documented in notes.
    • DC Diagnoses coded and indexed per facility policy.
    • MDS Discharge Tracking form completed within 7 days of discharge.
    • Nurses notes reflect physician notification
    • Nurses notes reflect family notification
    • Mortician Receipt completed.

    4.2.4 Focus Audits and Monitoring Systems

    There are other beneficial audit and monitoring systems, many of which should be in place on an on-going basis. Focus audits should be implemented based on the needs and issues of a facility. The following table lists the common monitoring and focus audits found in long term care facilities.

    Quantitative Monitoring Criteria
    Qualitative Monitoring Criteria
    Acute Problems/24 Hour Board(completed daily) Review the 24 hour or acute problem board each day. For each resident and problem identified check to see if corresponding documentation was completed such as nurses note, monitoring record, etc. Not only verify that the documentation was done, but also analyze what was documented. Does a note contain information applicable to the problem, should other issues be addressed? If an assessment or plan was documented was it appropriate? Should the documentation have included an assessment or plan?
    Weights Implement an on-going monitoring system when weights are recorded to note significant weight loss changes. If a significant weight loss has occurred review the documentation content to determine if the assessment and plan are complete and appropriate.
    Physician Visits Monitoring system to assure that physician visits are made and documented every 30 days for the first three visits and then every 60 days thereafter. Assure dictation is returned if applicable. Content of the progress note addresses or supports resident issues.
    Physician Orders/ Renewals Reviewed and signed by the physician within specified time frame. Renewal of orders completed timely (i.e. 30 or 60 days). Diagnosis can be associated with orders; Check for duplication of medications or treatments in treating a diagnosis.
    MAR/TAR Documentation completed at time of administration or within 24 hours if documentation omission occurs. Reason and results are documented for PRN administration.
    Physical Restraints Assessment completed and reviewed/updated at least quarterly. Consent obtained from resident or responsible party. Physician order obtained. Reason for restraint is appropriate to justify use.
    Skin/Pressure Sore Assessment completed and reviewed/updated weekly until healed. Documentation shows improvement or modification of plan if no improvement.
    Psychotropic, Antipsychotic, and Hypnotic Medication Use Assessment completed and reviewed/updated at least every 6 months. Physician order obtained. Diagnosis associated with medication is listed in the federal regulations as appropriate. Continued justification for administration of medication is documented. Dose reduction efforts are documented.
    Lab Result Monitoring Results of physician orders for all labs are in the medical record. Documentation reflects that abnormal lab results are communicated with physician.

    4.2.5 Integrating Audits/Monitoring into the QA/QI Program

    In order for an audit and monitoring program to be effective the data collected should be managed, analyzed, and reported. Findings from both focus audits/monitoring and on-going systems should be reported at the quality assurance committee meeting. Trends or problem areas should be identified and action taken to correct the negative finding. Using a quality improvement process, the problems identified through the audit should be analyzed, measures taken to correct the problem, and further monitoring to determine compliance.

    It is recommended that audit findings are plotted or graphed over time to show potential negative trends, the result of improvement efforts, or results of on-going monitoring. Not every audit or monitoring criteria warrants reporting and graphing. Facility administration, health information practitioners and the QA committee should determine which audit criteria are appropriate for on-going reporting and graphing.

    It is critical that the health information coordinator/manager actively participates in the quality assurance committee and process. If this is not possible due to level of staffing and level of expertise, it is acceptable to have other clinical staff assist in the collection of audit data and in the analysis and reporting process to the QA committee. Once on-going audit and monitoring processes are established, there is a system in place that can be adapted to the changing needs of the facility. For example, if a potential problem area is identified on the quality indicator report, the audit tools can be adapted to monitor related documentation issues as one method to analyze a possible problem. The elements of an effective audit and quality monitoring system include flexibility to adapt to the changing needs of the facility, formal reporting and correction methods, and administrative acknowledgement of the importance of proactive monitoring systems.

    4.2.6 Retention of Audits, Checklists, and Monitoring Records

    If checklists are placed on the chart, it is acceptable to leave them on the record, but only for the time frame defined on the tool and then it should be removed (eg. An admission checklist that is completed by day 7 should be removed right after the 7th day). It is not recommended the audit forms be left in the chart even discharge audit tools.

    The retention policies for the facility should define how long audits, checklists, and monitoring records should be retained based on the need and further use for the information. Generally, once the tool is completed and the findings are used for statistical analysis where applicable, the checklists/audit forms can be destroyed. If an audit is used in conjunction with a survey correction plan or monitoring a quality indicator, adjust the retention schedule appropriately.


    Processing of discharge records is an important aspect in management of record systems. For all records including discharge records it is the responsibility of the long term care facility to protect the records from loss, destruction and unauthorized use. Prior to final filing of a discharge record, audit and monitoring systems should assure that the record is complete. This section reviews the fundamental processes that should be in place when managing discharge records.

    4.3.1 Discharge Record Assembly

    Discharge assembly is the process of pulling together all medical records for a resident upon discharge and assembling the medical record into one combined chart (which can have multiple volumes) in the established discharge chart order. The established order provides for a discharge record that is systematically organized. It is recommended that a discharge chart order or order of filing be placed in each record to facilitate location and retrieval of information.

    Pulling Records from Multiple Locations:

    When assembling the discharge record pull records from all locations. For example, all overflow records for the resident, therapy records not yet filed in the chart, records kept in a separate notebook/cardex such as the MDS or care plan, records that are not kept in the chart such as an individual resident’s sign-out log kept in a sign-out book, and other records that have not yet been filed in the chart.

    Discharge Chart Order:

    Place the records in discharge chart order. Facility policy should define a specific discharge chart order that is used consistently for all discharge records. It is recommended that the discharge chart order remain the same as the in-house chart order to eliminate unnecessary time moving sections of the chart around. The only change that is recommended for the discharge chart order is to place the discharge documentation (discharge plan of care, transfer form, etc) at the front of the chart behind the face sheet/admission record. If there are records not normally kept in the chart during the resident stay, but filed on discharge, they should be added to the discharge chart order.

    The key to the assembly process is to establish one consistent chart order and date order for the forms and follow it consistently through all discharge records to establish systematically organized records that facilitate ease in retrieval of information. The following are the accepted methods for organizing discharge records.

    • Charts placed in discharge chart order running in chronological order.
    • Charts placed in discharge chart order running in reverse-chronological order.
    • Another approach when used systematically may reduce staff time yet allow for an organized record by placing the active chart in discharge chart order and maintain as volume one of the discharge record (either chronological or reverse chronological date order). The overflow records become the subsequent volumes of the discharge chart. A chart order or order of filing is placed at the front of volume one. The overflow records are placed in a defined chart and date order to use this method for assembling discharge records.

    Date Order for Discharge Records:

    There are two acceptable methods for the order of filing chart forms -- chronological date order (oldest records filed first) or reverse chronological date order (most recent records filed first). It is considered technically correct to file the discharge medical records in chronological order by form on the chart order (for example, all nurses notes kept together in chronological order, all physician orders recaps in chronological order, etc.)

    If defined by facility policy and consistently applied through the discharge record, forms could be filed in reverse-chronological order. If using a reverse-chronological order, all records in the discharge chart and on the discharge chart order should follow this organization.

    Fastening Discharge Records:

    To prevent loss or destruction of individual records, it is recommended that all discharge records be fastened in some manner. The most common methods include:

    • Two-pronged metal fasteners. If using a standard file folder, the prong should fasten the records to the file folder.
    • Specialty fastener rubber bands that are used for record storage. They have a life-span equal to the retention period for the medical records and fasten the records around both the length and width of the pages.
    • Pocket accordion folders in combination with a metal fastener or rubber band fastener. If using a metal fastener, it should not be fastened to the file folder since records must be lifted out of the pocket folder for review.

    Discharge Record Folders and Labeling:

    Discharge records should be placed in file folders that are labeled with resident identification information. The type of file folder used should be dictated by the storage method used for filing. For example, if using shelf filing the file folder should have a side tab to place resident identification information. If using drawer style file cabinets, the file folder used should have a top tab for resident identification information.

    At a minimum the discharge record file folder should be labeled with the following information: Resident full name, admission date, discharge date, medical record number and volume number. Other information which could be include on the label is the physician name and the discharge disposition (discharged home, another nursing home, expired, etc.). The number of volumes should be included on all discharge records even if there is only one record and should note both the volume number of that folder and the total volumes for that record (volume 1 of 2, etc.). It is recommended that a label with the discharge year be placed on the file folder to be used as a reference in the retention and destruction process.

    Other information and labels can be placed on the file folder to aid in filing and locating a record. Depending on how sophisticated of a filing system is used, color coded labels with information such as the first three letters of the last name or numbers in the medical record number provide additional assurances that records are filed correctly and can be located easily.

    In maintaining a unit record, the medical records from a previous stay should be pulled forward and kept with the current admission. Once the resident has been discharged from their most recent admission, the records from previous stays should be filed with the last admission. Do not integrate the records from a previous stay with the last admission. Keep the previous records in their file folders. Relabel the folder with the year from the most recent discharge. File the records from the previous stay in chronological order behind the last volume of the most recent stay.

    4.3.2 Discharge Record Analysis

    The process of analyzing a discharge record entails completing an audit of required discharge documentation before it is filed with the other discharge records. When completing discharge analysis the following steps should be completed:

    • Initiate a discharge audit form to record audit findings and deficiencies.
    • Check all pages of the medical record for resident name and medical record number. This will assure that a document if separated from the record can be traced back to the correct resident. Make sure that all documents belong to the correct resident.
    • Complete a discharge audit focusing on those elements outlined in discharge analysis in section 4.2.3 – Audits and Quality Monitoring.
    • Note on the discharge audit those items that are missing or incomplete. Note items that have been mailed or are waiting return.

    If the discharge audit is kept on the incomplete record, it should be removed before filing it with the other completed discharge records or when the record is requested by an outside party.

    4.3.3 Timely Completion of a Discharge Record


  • Written policies on record completion are in place and are consistent with accreditation standards, regulatory requirements, and medical staff guidelines.
  • Records should be assembled, analyzed, and completed within 30 days of discharge unless state law specifies another time frame. A record should be removed from the station as soon as possible after discharge. Records should be removed within 24 – 48 hours, but no more than 72 hours after discharge. The initial assembly and analysis should take place within 5 days of discharge. This leaves the remaining time to follow up on deficiencies and track documents that are being mailed and still allow for timely completion of the discharge record.

    4.3.4 Incomplete and Delinquent Records


  • Written policies outline the organization’s standards for the timely and accurate reporting of delinquent records.
  • Upon discharge analysis, records that have specific deficiencies that can be completed by a health care provider are considered incomplete. Once the audit has been completed, the providers should be notified of the incomplete records. They should be informed of the expectation to complete these records within a specific timeframe (within the 30 day or state-specific timeframe for timely completion of discharge records). Records should be monitored within the 30 day period to assure deficiencies are completed. If records have been mailed and were not returned in a timely manner follow up requests should be made for their return in time to meet the 30 day deadline.

    Once an incomplete medical record remains so after a defined period of time (over 30 days or over the state-defined timeframe), the medical record is considered delinquent. A long term care facility can develop a quality assurance monitor by calculating the delinquent record rate or reporting the number of delinquent records each month. To calculate the delinquent record rate divide the total number of delinquent records by the average number of discharges in a defined period. For example, if there are 30 total delinquent records and the average number of discharges for a 30-day period is 45 then the delinquent record rate is 67%.

    An on-going quality improvement process should be used to monitor the types of deficiencies in discharge records and the reasons for records to become delinquent, identify the causes for the deficiencies and delinquencies, and then implement corrective measures. The number of delinquent records, delinquent record rate and reasons for delinquency can be reported at the Quality Assurance Committee meetings. Completing a run chart with the number of delinquent records and delinquent record rate each month can show a pattern over time. When records cannot be completed, a process should be established to review and approve of records to be filed with the other discharge records as incomplete.

    4.3.5 Maintaining A Control Log for Discharge Records

    It is important to maintain a monitoring system or control log for managing the completion of discharge records. The following table can be used to track records through the process:

    Discharge Date

    Resident Name







    4.3.6 When to Close a Record on Temporary Absence

    Facility policy should define when a record will be closed upon a temporary absence and when it will remain open. Federal law does not dictate when records must be closed and when they remain open on a temporary absence. Most state laws do not address this issue, however, if there is a specific state statute follow the regulation. A temporary absence would be such events as a temporary leave of absence with or without a paid bed hold or a transfer/discharge to the hospital with the expectation of return with or without a paid bed hold.

    Long term care facilities should determine how they will handle closing records upon a temporary absence and consistently apply the policy in their facility. A good rule of thumb to help decide when to keep a record open upon a temporary absence is how the MDS discharge tracking form is completed. If it is indicated on the MDS discharge tracking form that the resident is not anticipated to return the chart should be closed and the resident discharged. If it is anticipated that the resident will return, facility policies should define whether the record will remain open or be closed. Facility policies should specify how each of the following situations will be handled and consistently applied. Policies may be different for each type of temporary discharge and/or by payer type.

    • Hospitalization with paid bed hold
    • Hospitalization without paid bed hold
    • Leave of absence with paid bed hold
    • Leave of absence without paid bed hold
    • Other types of temporary absences as defined by facility policy

    There are advantages and disadvantages to each option outlined below.

    • Keeping a Record Open Upon Discharge for a Temporary Absence: One option is to keep the record open during a temporary absence rather than closing the record on the discharge/transfer date. The advantage to keeping the record open is to minimize the time in readmitting and reassessing the resident. The information prior to the temporary absence continues to be available rather than in another record that is less accessible. The disadvantage of leaving the record open is the lack of consistency between the admission and discharge date, the financial record, and the medical record.

      If the record remains open, policies should define the maximum length of time a record will remain open. Some payers such as Medicaid may define a bed hold period which can be followed in developing a time frame on keeping a record open. In absence of a state or payer specific guideline, keep a record open for no more than 14 days. If the resident has not returned within a 14 day period, the chart should be closed. The discharge date is the date the resident left the facility.

      When the chart remains open, the medical record should be removed from the nursing station or flagged for an absence or leave. This will help prevent staff from charting when the resident is no longer in the facility. A common practice is to redline the chart with a hospitalization. The pages in the record used for cumulative or on-going documentation such as progress notes, orders, flowsheets, or medication and treatment records are lined with a red pen with the hospital dates noted. This provides a visual break or flag in the record.

      Upon return from a temporary absence, facility policy should also define the documentation to be completed when the resident returns. The reason for the discharge will affect the type of documentation to be completed. A return from a 5 day leave of absence will probably not require the same type of reassessment as a return from a 5 day hospital stay. When the resident is readmitted, all of the current assessments and care plan should be reviewed and updated, a readmission physical assessment completed, an assessment for significant change in condition, readmission/assessment notes written by all disciplines, and new physician orders initiated.
    • Closing the Record with a Temporary Absence: Another option is to close the record upon the discharge date for the temporary absence. Closing the record keeps the admission and discharge dates consistent with the financial record and medical record. If the record is closed, records from the last stay must be brought forward to the new record to assure access to important clinical information and provide continuity of care.

    When pulling documentation forward to the new record a copy of the following documentation should be made: last MDS (if resident was expected to return from the temporary absence, the MDS schedule should resume not start over), advanced directives, social history, immunization records, leisure interest survey, copy of last progress notes, preadmission screening documentation (PASARR). Closing Records with a Change in Level of Care

    The medical record should not be closed when there is a level of care change between NF and SNF – the same record should remain active through the level of care change. If a long term care provider offers services in a variety of licensure settings, organization policies should define how transfers between different levels of care will be handled. Transfers between similar levels like NF and SNF should not result in the closure of records. Major changes in level of care such as a transfer between an assisted living facility to a SNF should result in the records being closed if the resident does not anticipate returning to their previous living situation. If a resident anticipates a return, organization policies can determine if records will remain open, the maximum length of time records will remain open, or if they will be closed. Closing Records with a Payer Change

    The medical record should not be closed upon change in payer such as a change from Medicare to private funds. A change in payment status does not warrant separating the medical records into different stays. The financial office should have mechanisms to track dates of coverage by individual payers.


  • The healthcare organization’s and health information management department’s filing systems, policies, and procedures comply with federal and state regulations and accepted standards of practice to ensure that all health records and resident-identifiable data are well organized and readily available for resident care, research, education, and other authorized uses.
  • Policies and procedures exist to facilitate the prompt, consistent, uniform, and efficient filing of all health records and resident-identifiable data.
  • The filing system is designed and implemented to ensure the safety, security, and accuracy of health records and resident-identifiable data.
  • Policies and procedures exist to facilitate the prompt, consistent, uniform, and efficient retrieval of all health records and resident-identifiable data, and the policies and procedures ensure that confidentiality is maintained and that retrieval is performed only by authorized persons.
  • The retrieval system is designed and implemented to ensure that safety, security, and accuracy of health records and resident-identifiable data; to keep track of the locations and holders of health records and resident-identifiable data removed from files; to follow up at appropriate intervals on the return of health records and data; and to identify health records and data to be converted to alternative medium moved to inactive storage, or destroyed.
  • Every long term care facility should have established a system for filing and retrieving of their medical records. The sophistication of the filing system is dependent on the volume of filing, admissions, discharges, and requests for records. Only trained staff should have access to the records and perform the filing and retrieval functions.

    4.4.1 Separate Location for Incomplete Records

    It is recommended that incomplete medical records be kept in a separate location in the department rather than integrated with all of the discharge medical records. An incomplete record area facilitates ease in retrieval for staff who are completing records and also provides for easier monitoring of incomplete records.

    4.4.2 Typical Filing Systems

    There are many acceptable methods for filing medical records ranging from the simple (alphabetical filing) to the complex (terminal digit filing). The type of system selected is based on facility-specific factors such as the volume of filing, admissions, discharges, requests for records, filing space, storage (open shelf filing vs. file cabinets) and security concerns. The following are the most common filing systems used in long term care for discharge records and overflow records:

    • Records are filed alphabetically by discharge year. This method is commonly used when there is limited space in the health information department to retain more than one year of discharge records. Alphabetic filing provides the easiest for retrieval of records. Special systems are not required to locate a resident’s record. This method offers the least security since anyone could locate a resident record.
    • Records are filed alphabetically with multiple years integrated together. A color-coded label is placed on the tab of the folder to indicate the discharge year. When there is adequate storage in the health information department, multiple years of records are integrated and filed alphabetically.
    • Records are filed numerically by medical record number by discharge year. Records are filed by medical record number in numeric order for a single discharge year. This method offers better security than alphabetic filing because the medical record number must be known to locate a record. Access is more difficult for supervisory staff who must access records when the health information department is closed.
    • Records are filed numerically by medical record number with multiple years integrated together. A color-coded label is placed on the tab of the folder to indicate the discharge year. Multiple years of discharges are integrated together and filed by medical record number when there is more filing space in the health information office.

    4.4.3 After Hours Retrieval

    Every facility should have a process in place for after hour retrieval of records in case of an emergency. Because evening and night shift staff may have to complete deficient discharge records or have access to an overflow record, the supervisor should have keys to access the department and be trained in retrieval, the sign-out process, and other security measures. Department procedures should track who has keys to the department and documentation of their training on filing and retrieval procedures.


  • Policies and procedures exist to facilitate the storage of both active and inactive health records and resident-identifiable data and are evaluated periodically to ensure that health records and data are well organized, are kept confidential and secure, and are readily available for resident care, research, education, and other authorized uses.
  • The storage system is designed and implemented to ensure the safety, security, and accuracy of health records and resident identifiable data.
  • When storage plans are developed, consideration is given to the amount of space needed and available, the expected future demand for storage space, the costs of various storage alternatives and associated personnel, and the healthcare organization’s health record and data retention policies.
  • Long term care facilities must invest in adequate storage systems and storage space for their medical records. The storage methods and systems must be secure and protect the confidentiality of resident information. The storage system and space must be adequate to protect the physical integrity of the record and prevent loss, destruction, and unauthorized use.

    4.5.1 Storage System Options:

    Medical record storage systems should be of professional quality to house and protect the medical records. Office supply and medical record file and storage vendors offer various products ranging from simple file cabinets to mobile file storage systems. The most common found in long term care are open shelf filing shelves (with or without locking doors) or metal drawer file cabinets. The storage method selected is dependent on the security of the health information office and the amount of storage. If the office is to be shared with another staff member or department not in health information, the shelves or file cabinets must be lockable and kept locked when ever health information staff are not in attendance.

    The goal in each facility should be to keep accessible as many years as possible of discharge records.

    • Open shelf filing: Open shelf filing is a common filing method for medical records in various practice settings in health care. Open shelf filing allows for easy access to files. The file folders used with open shelf filing must have side tabs for viewing demographic information for identification.

      If medical record files are retained in the health information office that is not shared with other staff or in a separate locked file room, open shelf filing without lockable doors is acceptable. The office should always be locked when staff is not in attendance. If the office is shared, the open shelf filing should have doors that are lockable. When the health information staff member is out of the office, all medical records should be in locked files.
    • File cabinets: Two, four or five drawer metal file cabinets are also commonly used in long term care facilities. File cabinets work well when there are few discharges in a year and storage space is minimal. Because file cabinets are bigger and bulkier than open shelf filing, they are not the optimal choice for large storage rooms or offices with a large volume of discharge medical records.

      Locked file cabinets should be used when the health information office is shared with another staff member. The cabinets should be locked whenever the health information staff is not in the office.

    4.5.2 Security Issues: Locking of Office and Storage Areas

    The health information office and storage areas must be kept secure at all times if medical records are filed and stored in that area. If the office is only used for health information staff, open shelf filing can be used in the office.

    When health information staff leaves the office, all doors or access to the office must be locked. The office should not be unattended when there are records on open shelving. If the office is not to be locked, then all filing shelves or file cabinets must be locked. No records should be out in the open and left unattended.

    If the office is to be shared with another staff member or department not in health information, the shelves or file cabinets must be lockable and kept locked whenever health information staff are not in attendance.

    Storage areas outside of the health information office should be locked with access limited to only those who need access. Health information department policies should identify who has keys and training on access, security, and the log-out process for records.

    4.5.3 Alternative Storage Areas

    When there is not enough room in the health information office to store all discharge medical records for the defined retention period, it is necessary to locate alternative storage. Optimally the storage should be in the facility to facilitate retrieval, but when storage space is limited it may be necessary to utilize storage space outside of the facility. When an alternative storage space is needed, the space selected must be secure and must protect the records from damage, loss or destruction.

    Storage rooms must be organized allowing for ease in location and retrieval of records and documents. Similar documents should be retained together. One method for tracking the location of documents that are retained is to maintain an index log for records/documents (other than personnel files and medical records) which identifies the contents of different storage containers and locations. A log would contain information on the box number and a description including dates of items in the box.

    • Storage Boxes: When it becomes necessary to store inactive discharge records and other resident-specific documents, storage boxes may be used. Storage boxes should not be considered for recent years of discharge records when records are accessed more frequently. Storage boxes purchased should be of adequate quality and durability for record/document storage purposes.

      If storage boxes are used they must be adequately labeled with the content of the box, the year, and the year the records may be destroyed (per facility retention guidelines). It is recommended that similar types of documents are kept together in a storage box to facilitate ease in destruction.

      When storage boxes are used, they should not be stacked on top of each other. Boxes should be placed on shelves to facilitate easy retrieval of records and documents. Boxes should be placed off the floor and below sprinkler heads following state fire safety standards. In absence of a standard, boxes should be at least 18" off of the floor and 18" below sprinkler heads.

    • Storage Rooms: If storage rooms are used for medical records and other confidential records, they should be kept organized with adequate shelving, lighting and security. Multiple use storage rooms in which multiple staff members have access or keys must have a separate area that is caged and locked to protect the security of confidential records and documents. The storage room environment should not cause damage to the records and documents (such as moisture or rodents). It is acceptable to use storage boxes, but it would be optimal to use metal files or cabinets.

    • Storage Buildings/Sheds/Rented Storage: When storage buildings or sheds are used for confidential documents, records and documents must be secure and protected from loss or destruction. The same standards apply to storage buildings, sheds and rented storage that applies for storage rooms within a facility. If multiple staff have access to the shed and store items, the records and documents must be placed in a separate locked area with access by select staff. The storage building must protect records from the elements such as moisture and rodents. The storage area must be organized to facilitate location and retrieval of information. Although it is acceptable to use storage boxes, it is optimal to use metal cabinets or files.

      In some states prior approval is required from the Department of Health for use of off-site storage.
    • Storage Companies: If a storage company is selected, they should have written policies on the security and safety of confidential records and documents. If using a storage company there should be a written contract or agreement in place outlining the storage companies responsibility in securing documents, protecting documents from loss or destruction, and outlining how facilities will access records and the time frame for obtaining records. The long term care facility should have a list of all resident medical records and other documents retained at the storage company and have mechanism to access to those records in an emergency situation.



  • The healthcare organization’s and health information management department’s health record and data retention systems, policies, procedures, and specified periods of retention comply with federal and state regulations; certification, licensure and accepted standards of practice.
  • The retention system is designed and implemented to ensure the safety, security, and accuracy of health records and resident-identifiable data, and it considers the needs of all legitimate users of health records and resident-identifiable data.
  • Health information management department provides assistance to other departments in developing retention schedules for their records, data, indexes, and reports.
  • Facility policy should define a specific retention schedule for different types of records based on federal and state law and professional practice standards. The policy should be consistently applied and records destroyed after the retention period has expired. Storage areas should be organized and storage boxes labeled with the content, year of documents, and year records/documents can be destroyed.

    4.6.1 Retention Guidelines

    The following retention schedule outlines federal guidelines and recommended retention guidelines. If State law requires a different retention period, the more stringent between federal and state must be followed. After considering the required retention period, every facility should define in policy their specific retention period not to be less than the period defined by state or federal law.

    Document Type

    Federal Regulation

    AHIMA Recommended Guideline

    Medical Record

    (F515) 5yrs after discharge when there is no requirement by state law; For minors, 3 years after the resident reaches legal age as defined by state law. Medicare residents – 5 years after the month the cost report is filed (HIM 12 Medicare Manual).


    Financial Record

    Medicare residents – 5 years after the month the cost report is filed.


    Master patient index



    Admission/Discharge Register



    Disease Index


    10 Years

    OSHA Records/Employee MR

    Duration of employment plus 30 years

    Accounting of Disclosure Information (Release of Information Log) 6 years (HIPAA Privacy Rule)  



  • The healthcare organization’s and health information management department’s health record and data destruction systems, policies, and procedures comply with federal and state regulations and accepted standards of practice.
  • Policies and procedures exist to facilitate the destruction of health records and resident-identifiable data.
  • The destruction system is designed and implemented to ensure the security and confidentiality of the health records and resident identifiable data being destroyed.
  • Every long term care facility should have a policy and procedure established to destroy records or confidential documents that are beyond their retention period. At least annually, every facility should review the documents on the retention guideline and destroy records as appropriate. It is recommended that the Executive Director/Administrator be notified and approve of records/documents to be destroyed.

    4.7.1 Acceptable Methods of Destruction

    Records containing resident-identifiable data must be destroyed in a manner that makes it impossible to reconstruct and read the information. Records and resident information cannot be disposed of in the garbage containers without some type of shredding or obliteration. Acceptable methods used today include shredding, incineration:, and pulverization. If facility staff are used to shred records, the health information staff should oversee the process. If the records are destroyed off-site through a destruction company, a certificate should be obtained attesting to destruction of records.

    4.7.2 Abstracting Documents Prior to Discharge

    Unless required by state law it is not necessary to abstract documents out of the record to retain on a permanent basis. The master patient index card and the destruction logs contain basic demographic information and are to be retained on a permanent basis.

    4.7.3 Destruction Logs and Witnesses

    In addition to written policies and procedures on retention and destruction, it is recommended that a facility maintain documentation of the records/documents that are destroyed and the dates information was destroyed. Two types of destruction logs are recommended. One log should be used to reference when different types of documents were destroyed, when they were destroyed and who they were destroyed by.

    Sample Destruction Log (Multiple types of documents)

    Document Name

    Facility Retention Period

    Dates Destroyed

    Person Authoring Destruction

    Destroyed By and Witnessed By

    Destruction Date

    Resident Medical Records

    7 years


    Billing Records

    7 years


    Disease Index

    10 years


    When medical records are destroyed, documentation of the destruction process and individual records destroyed must be in place. There are a number of methods that can be used to document records that have been destroyed. A destruction log is a common process used to document the resident's name and the minimal demographic information for records that are destroyed. The destruction log also must contain the date of destruction, method of destruction, who destroyed the records and the witness, and a statement that the records were destroyed in the normal course of business. The medical record destruction log should be retained with the destruction log shown above.

    Sample Medical Record Destruction Log (Individual Resident Records)

    Resident Name

    Medical Record No.

    Admission Date

    Discharge Date

      Date of Destruction: __________ Destroyed By: ____________ Witness: ______________

    If an off-site record storage company or destruction company destroy records, they should supply a certificate of destruction that is signed and witnessed and includes a list of the items destroyed, the date of destruction and method of destruction. The LTC facility should have a written agreement with the destruction company detailing their procedures and their security measures.



  • When the healthcare organization uses a manual record-tracking system, out guides and/or requisition slips are used consistently to indicate records removed from the files.
  • Training on the organization’s record-tracking system is provided to all healthcare employees empowered to request access to health records.
  • 4.8.1 Maintaining a Record Check-Out System

    One of the most important physical security measures that must be in place in every long term care facility is a record sign-out system (log-out and/or outguides) for all types of medical records. Not only do the systems have to be in place, but they must also be enforced to be effective. Health information staff should monitor the sign-out practices and assure that records are returned promptly.

    • Active Records: Outguides or a sign-out system must be in place on all nursing stations. Charts should not leave the unit without being signed out. Outguides work well because they are placed in the chart rack where the chart was removed. The authorized person who took the record must be identified along with the date and location.
    • Overflow Records: Regardless of where overflow records are located in the facility, there must be a sign-out process to identify when a record has been removed, who took the record, and where it is located.
    • Discharge Records: A sign-out system must be in place when a record is removed from the health information department or record storage area.

    4.8.2 What to do if a Record is Lost , Destroyed or Stolen:

    Even with the best preventative systems in place medical records, in full or in part, can be inadvertently lost, destroyed, or stolen. To limit or minimize the harm, systems must be in place and enforced which protect the records.

    When records are lost or missing, an exhaustive search should be conducted to locate the documents or records. Once records are found, evaluate the system failure that resulted in the loss of records and implement corrective measures to prevent it from occurring again.

    After an exhaustive search for lost records or in situations where the records are known to be destroyed or stolen, the next step is to reconstruct the record if possible.

    Reconstruct the information by:

    • Reprinting documents from any databases, such as the facility clinical computer system (MDS, care plans, etc), pharmacy (current physician orders), laboratory, and radiology databases or data backup services.
    • Retranscribe documents from the dictation system if used (check with attending physician for copies of dictated progress notes).
    • Obtaining copies from recipients of previously distributed reports/documents, such as those sent to physician's offices, hospital, other healthcare facilities, or the business office.
    • Obtain copies of reports generated by a healthcare facility (hospital) that relate to the resident’s stay (history and physical, discharge summary, emergency room reports, etc.).
    • If the current record is missing, have staff complete baseline assessments for the resident, complete a comprehensive assessment and a new care plan. Have each discipline write a summary note with the resident history and progress over the course of their stay. Verify physician orders with attending physician and have reconstructed orders signed.

    If unable to reconstruct part or all of a resident's health information, document the date, the information lost, and the event precipitating the loss in the resident's record. When appropriate, document what and how information was reconstructed. Authenticate the entry as per facility policy. When information is disclosed that would have normally included the missing portion, include a copy of the entry documenting the loss of that information.

    4.8.3 Disaster Plans


  • A disaster plan for recovering health records damaged by fire, flood, or other destructive events is in place.
  • The disaster plan includes provisions for recovering healthcare records on different types of storage media.
  • The disaster plan includes provisions for a backup system to provide the healthcare organization’s staff necessary access to health records during emergency situations.
  • Every long term care facility should have a disaster plan in place to deal with unexpected events and outline how health information/medical records will be protected from damage. A well thought out disaster plan will minimize disruption, ensure stability, and provide for orderly recovery when faced with an unforeseen event.

    A plan should be in place to deal with water damage (flood, sewage back-up, sprinkler damage, etc), fire, power failures (electronic medical records and clinical information systems), resident evacuation, and other natural disasters common to your area such as a hurricane or tornado.

    AHIMA has the following practice brief on disaster planning which details the steps to take in preparing for potential adverse events.


    • Perform a literature search on disasters and disaster planning relative to medical records or health information. Search the archives of your favorite health information listservs or Web sites. Check the Internet to see if other health organizations have posted disaster plans on their Web sites. Collect sample health information disaster plans from peers.
    • Talk to colleagues who have experienced the types of disasters your facility could expect.
    • Contact several fire/water/storm damage restoration companies to determine the services available in your area and obtain any instructional information they can provide. Services may include document, electronic media, and equipment restoration as well as storage. These companies can often be located in the yellow pages under "fire/water damage restoration" or in the Disaster Recovery Yellow Pages.7
    • Determine to what extent the facility's insurance covers the costs associated with moving health information, operating elsewhere, recovering damaged information, or lost revenue secondary to the inability to restore information. In addition, determine whether your insurer offers consultation and advice on disaster planning. Many insurers provide this at little or no cost to their clients.

    Drafting the Plan

    • List the various types of disasters that might directly impair the operation of the facility, such as fire, explosion, tornado, hurricane, flood, earthquake, severe storm, bioterrorism, or extended power failure.
    • List your department's core processes. For example, at a large hospital, the core processes might be maintenance of a correct master patient index (MPI), assembly, deficiency analysis, coding, abstracting, release of information, transcribing dictation, chart tracking, locating and provision, and generating birth certificates.
    • Correlate the disaster plan/recommendations to the facility disaster plan mandated under Life/Safety codes.
    • Make sure facility insurance policy addresses record restoration in case of damage.

    For each plausible disaster and core process, generate a contingency plan. The document might include:

    • facility name
    • department name
    • contingency plan originator
    • date
    • the major function being addressed, such as chart tracking and location and provision
    • the disaster being considered, such as a hurricane
    • assumptions about the disaster, such as how will the disaster affect utilities; staffing and the ability of staff to report to work; security of health information and the facility itself; hardware and software; equipment and supplies; other departments; and residents presenting to the facility for treatment
    • description of the existing process used for the major function being addressed
    • an if/then scenario stating what will happen if a specific function cannot be performed
    • interdependencies, such as which processes depend on the provision of certain information or services
    • solutions and alternatives, including steps that can be taken to minimize damage or disruption before the disaster, ensure stability, or provide for orderly recovery
    • the limitations and benefits of each solution or alternative
    • activities that will need to be performed before the disaster in order to make this alternative possible, such as equipment acquisition, implementation of back-up systems, and development of disaster-related forms, materials, procedures, and staff training
    • the names of the individuals responsible for performing these activities
    • a list of individuals and departments with phone numbers to be contacted or notified relative to the disaster and implementation of this particular contingency plan

    Implementing the Plan

    • Perform the preparatory activities listed in each of the contingency plans.
    • Share the preliminary plans with the facility's safety officer and risk manager.
    • Develop written agreements with potential disaster recovery vendors or alternative service providers and locations as needed.
    • Provide staff with the training and tools necessary to implement the plan.
    • Test the plan.
    • Reevaluate and revise the plan and corresponding procedures based on the input of staff, the safety officer, and the risk manager, and on simulated disaster trials.
    • Include disaster training as part of staff orientation.
    • Measure staff competency by asking staff to describe or demonstrate their roles and responsibilities during specific disasters. Include competencies in staff performance standards.
    • Conduct drills at least semiannually.
    • Review and update the plan at least annually.
    • Repeat training and test competencies at least annually.

    Restoring Damaged Records

    In the event records are damaged in an actual disaster, contact a fire/water/storm damage restoration company. If services are contracted, the contract must provide that the business partner will:

    • specify the method of recovery
    • not use or further disclose the information other than as permitted or required by the contract
    • use appropriate safeguards to prevent use or disclosure of the information other than as provided for by the contract
    • report to the contracting organization any inappropriate use or disclosure of the information of which it becomes aware
    • ensure that any subcontractors or agents with access to the information agree to the same restrictions and conditions
    • indemnify the healthcare facility from loss due to unauthorized disclosure
    • upon termination of the contract, return or destroy all health information received from the contracting organization and retain no copies
    • specify the time that will elapse between acquisition and return of information and equipment
    • authorize the contracting entity to terminate the contract if the business partner violates any material term of the contract

    To the extent records cannot be reconstructed by the damage restoration company, reconstruct the information by:

    • reprinting documents from any undamaged databases, such as admission, transcription, laboratory, and radiology databases or data backup services
    • retranscribing documents from the dictation system
    • obtaining copies from recipients of previously distributed copies, such as physicians' offices, other healthcare facilities, or the business office

    If unable to reconstruct part or all of a resident's health information, document the date, the information lost, and the event precipitating the loss in the resident's record. When appropriate, document what and how information was reconstructed. Authenticate the entry as per facility policy. When information is disclosed that would have normally included the missing portion, include a copy of the entry documenting the loss of that information.

    Create and retain a record of the disaster event and a list of resident records affected, with recovery efforts, successes, and failures. This will allow for easy retrieval of general information regarding the past event should any legal or accreditation issues arise.

    Post Disaster

    Following the disaster, meet with staff and allow them the opportunity to:

    • evaluate departmental performance and identify opportunities for improvement
    • begin the grieving and healing process that may follow emotionally charged disasters

    Disaster Plan Practice Brief prepared by: Gwen Hughes, RHIA Professional Practice Division



  • The medium in which resident-identifiable data and healthcare information are stored, whether paper based or computer based, is the property of the healthcare organization and is maintained to serve the resident, the healthcare professional, and the healthcare organization in accordance with legal, accrediting, licensing, regulatory, and ethical standards.
  • Resident-identifiable data and healthcare information, regardless of the medium in which they are stored, belong to the resident and are protected accordingly.
  • Confidentiality policies and procedures specify that resident-identifiable data and healthcare information are used within the healthcare organization only for the purposes for which the data and information were collected.
  • Disclosure of resident-identifiable data and healthcare information is restricted to those individuals who possess knowledge of applicable federal and state laws and regulations and training in the legal ramifications of subpoenas and court orders.
  • One of the most critical roles of the health information department is to monitor and apply regulations, professional practice standards, and facility procedures for protecting resident confidentiality, information security, and release of information. A comprehensive policy and procedure on confidentiality and release of information must be in place in all long term care facilities. The following guidelines provide direction on common issues related to confidentiality and release of information. The guidelines take into consideration federal laws and professional practice standards, but not individual state regulations. If there is a state specific law with more stringent requirements, follow the laws of your state.

    Federal Regulation: 42 C.F.R. § 483.75 (4) states: The facility must keep confidential all information contained in the residents’ records, regardless of the form or storage method of the records, except when release is required by – (i) transfer to another health care institution; (ii) law; (iii) third party payment contract; or (iv) the resident.

    The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that requires healthcare facilities and payers who utilize standardized transactions (such as electronic billing) to comply the Standards for Privacy of Individually Identifiable Health Information (HIPAA Privacy Rule). The HIPAA privacy rule became final on April 14, 2001 with compliance required by April 14, 2003. This section refers to various components of the privacy rule, but does not go into full detail on all requirements. It is recommended that health information practitioners obtain a copy and review the entire HIPAA privacy rule. Copies can be obtained through the Administrative Simplification website at

    4.9.1 Identification of Confidential vs. Non-confidential Information


  • Resident-identifiable data and healthcare information are regarded as confidential and made available only to users authorized within the healthcare organization, users authorized by the resident or his/.her legal representative, and users authorized by law.
  • Confidentiality policies and procedures differentiate between confidential and non-confidential data and information.
  • Policies and procedures address the heightened level of confidentiality provided to healthcare information related to behavioral health, substance abuse treatment, HIV/AIDS, abortion, and adoption.
  • The confidentiality/release of information policy should define what information is considered non-confidential and may be disclosed without an authorization and that which is considered confidential. State law may define non-confidential information. Federal law restricts disclosure of information related to drug and alcohol abuse treatment. Under the HIPAA privacy rule, disclosure of directory information is permitted without a consent or authorization as long as the resident has had an opportunity to agree or restrict its use. Directory information may be disclosed to individuals who ask for the resident by name. Healthcare facilities are under no obligation to disclose even non-confidential information, policies should define the facility practice. The resident population should be considered when deciding what is considered non-confidential. Special consideration may be given to celebrities, facilities who treat HIV/AIDS residents, behavioral health facilities, etc.

    • Non-confidential or directory information is considered to be common knowledge such as name of the resident, location in the facility (room number), their condition described in general terms (critical, stable, good, fair, transferred, treated and released, or expired), and religious affiliation.
    • Confidential information is information made available during the course of a confidential relationship between the resident and healthcare professional. Confidential information includes – but is not limited to – all clinical data and the resident’s address on discharge. Confidential information may be disclosed only when the resident, or the resident’s legal representative, gives written authorization, or when federal or state law, subpoena, or court order requires such disclosure.

    Facility policies should give direction to staff on releasing non-confidential and confidential information. Since these situations often occur at the receptionist desk or at the nursing station, staff should receive special training in dealing with requests and deciding what is acceptable to release and what is not.

    4.9.2 Resident Access to Their Records


  • Subject only to specific legal constraints (such as those governing minors and persons adjudicated incompetent), a resident or his/her legal representative has access to and is provided photocopies of his/her health record upon written request with reasonable notice and payment of a reasonable fee.
  • Policies and procedures have been established to enable the resident to review, amend, or correct his/her health record.
  • By federal law, residents or their legal representative in a long term care facility have the right to access their medical records. Facility policies should provide guidance on who is considered a legal representative based on State law (i.e. guardian, conservator, durable power of attorney, etc.) Facility procedures should also outline how each request – whether a review of the medical record or request for photocopies -- will be handled.

    C.F.R. § 483.10(b)(i) states that "the resident or his or her legal representative has the right, upon oral or written request, to access all records pertaining to himself or herself including current clinical records within 24 hours (excluding weekends and holidays)." In the event the resident or the representative wants a copy of the medical records, the facility is required to make copies, after 2 working days advance notice, "at a cost not to exceed the community standard." 42 C.F.R. § 483.10(b)(ii).

    Under the HIPAA privacy rule, the resident has the right of access to inspect and obtain a copy of their protected health information in a designated record set (medical record) as long as the information/record is maintained. The facility must act on the request no later than 30 days after receipt. If records or information are not maintained on-site, the facility has up to 60 days to act on the request. The federal regulation for nursing homes (483.10(b)(i)) requires a more stringent time frame and should be followed when acting on a request by the resident/legal representative to access records.

    Steps In Handling A Request To Access/View Medical Records:

    • When a request is made by the resident or another party to view the medical record, those requests should be directed to the health information coordinator. Selecting one person or a department to handle requests will help to assure that the policy is carried out uniformly and information isn’t inappropriately disclosed or withheld.
    • If the requestor has the legal authority to view the record, a meeting should be set up within the 24 hours required by law. If the requestor cannot accommodate a meeting within the 24 hour time frame, the review should be set up at a mutually agreed upon time. Since the resident or their legal representative have the right to review their records under federal law, it is not necessary to get approval from their attending physician.
    • Prior to the meeting, the record should be reviewed. All records from another facility (i.e. hospital from a prior stay or another nursing home) should be removed.
    • During the meeting, a staff member should be in attendance at all times. The staff member can be from the health information department or a designee such as nursing or social service. The staff member present at the meeting is there to answer questions and to assure that the record is not altered in any way or documents removed/destroyed. The resident/legal representative should be allowed to review and read the record without intervention from the staff member present.
    • If copies are requested during this meeting, a release of information form should be signed with the specific documents and dates listed. The facility’s copy charge policy should be disclosed to the resident/legal representative at the time of the request. By law, the copies must be made within 2 working days of the request.

    Steps In Handling A Request for Copies of Medical Records:

    See the sections on Handling a Request for Medical Records and Copy Fees for Medical Records. The request for copies should be put in writing on a Release of Information form and signed by the resident or legal representative (for tracking purposes). The request should specifically state what records are to be copied. Review the copy fee policy with the resident/legal representative and if known, the estimated cost to fulfill the request before copies are made. To comply with the federal regulation, the copies must be made within 2 business days.

    4.9.3 Confidentiality Training and Agreements with Employees and Volunteers


  • Education and training programs provided to members of the healthcare organization as a whole and to specific departments address the confidentiality of resident-identifiable data and healthcare information.
  • Confidentiality policies and procedures are incorporated into new employee orientations and routinely reviewed as part of each employee’s ongoing education.
  • Education and training programs on confidentiality address the responsibilities of staff to protect the resident’s right to privacy.
  • Confidentiality agreements are signed by everyone connected with the healthcare organization who may have access to confidential healthcare information and resident-identifiable data, and the agreements are updated annually.
  • Agreements with home-based employees state that the employees assume the same responsibility as regular employees for maintaining the confidentiality of all resident-identifiable data and healthcare information within their control.
  • Education and training programs provided to members of the healthcare organization as a whole and to specific departments address the release of resident-identifiable data and healthcare information.
  • Long term care facilities should have confidentiality training programs in place for all employees and volunteers. Training should be provided at the time of hire and reviewed annually with employees/volunteers. Training should address the employees responsibility in maintaining the resident’s privacy, the facility’s confidentiality and release of information policies, common situations which an employee may face which could result in a breach of confidentiality, and the consequences if a breach occurs or policy is not followed. All employees should have some basic training on their responsibility. Staff who handle requests for information should have additional training to address the situations they will face in their position.

    Under HIPAA, facilities must train all members of its workforce on their policies and procedures related to the privacy rule. The training should be based on employee's function within the facility. Training for the entire workforce must be completed by the compliance date (April 14, 2003 at the latest). After the compliance date, all new members of the workforce must be trained within a reasonable period of time. Retraining must occur when there is a policy or procedure change that affects an employee's job. The facility must document that training was provided.

    In addition to training, long term care facilities should have employees, students, and volunteers sign a confidentiality agreement at the time of employment after they have received training. Facility policies should address the frequency for obtaining updates to the agreement (i.e. annually after training). It is not recommended that confidentiality statements/agreements be incorporated into employee handbooks where the employee signs a blanket statement at the end. With the privacy requirements in the Health Insurance Portability and Accountability Act (HIPAA), it is recommended that confidentiality agreements should be separate and above the employee handbook to stress the importance of maintaining resident privacy and the potential action if privacy is breached.

    The following sample provides language developed by AHIMA for discussion purposes only and published in the book, Release and Disclosure, Guidelines Regarding Maintenance and Disclosure of Health Information by Mary Brandt, MBA, RHIA, CHE. It should not be used without review by your organization’s legal counsel to ensure compliance with local and state laws.

    Employee/Student/Volunteer Nondisclosure Agreement

    [Name of healthcare facility] has a legal and ethical responsibility to safeguard the privacy of all residents and to protect the confidentiality of their health information. In the course of my employment/assignment at [healthcare facility], I may come into possession of confidential resident information, even though I may not be directly involved in providing resident services.

    I understand that such information must be maintained in the strictest confidence. As a condition of my employment/assignment, I hereby agree that, unless directed by my supervisor, I will not at any time during or after my employment/assignment with [name of healthcare facility] disclose any resident information to any person whatsoever or permit any person whatsoever to examine or make copies of any resident reports or other documents prepared by me, coming into my possession, or under my control, or use resident information, other than as necessary in the course of my employment/assignment.

    When resident information must be discussed with other healthcare practitioners in the course of my work, I will use discretion to ensure that such conversations cannot be overheard by others who are not involved in the resident’s care.

    I understand that violation of this agreement may result in corrective action, up to and including discharge.

    [Signature and date of employee, student, or volunteer]

    4.9.4 Resident Identification Boards at Nursing Stations and Other Facility Locations

    It is common to find boards at the nursing station or in other areas of the facility that are viewable to the public and identify resident-specific information considered confidential. These boards have been used to identify the nursing assistant they are assigned to, clinical information for communication to other shifts, census information, etc. As a general rule, the only resident boards that should be viewable to the public provide directory information (room number). Other communication boards viewable to the public, other residents or staff members who do not have a need to know, should not be in a location where confidential information is viewable.

    4.9.5 Maintaining an Access/Disclosure Grid for Employees, Contractors and Outside Parties


  • With regard to access to resident-identifiable data and healthcare information, the healthcare organization’s and health information management department’s policies differentiate among levels of authorized users within the healthcare organization, users within the healthcare organization’s provider network, and third-party users external to the healthcare organization and its provider network.
  • Contracts for services external to the healthcare organization state that the companies providing the services assume responsibility for maintaining the confidentiality of all resident-identifiable data and healthcare information within their control.
  • Policies and procedures identify when disclosure of resident-identifiable data and healthcare information may be made without the resident’s consent and differentiate between mandatory disclosure (for example, reporting of child abuse) and permissive disclosure (for example, access by healthcare staff).
  • Policies and procedures define those circumstances that require resident authorization and those that do not before resident-identifiable data and healthcare information may be disclosed.
  • Policies and procedures identify those communicable diseases and other public health threats that require reporting to the appropriate governmental agency and the mechanism by which the reporting is to be done.
  • Part of the facility policies on confidentiality should be an access grid that outlines which employees and contractors are considered authorized users of the medical record and any restrictions or limitations on what can be accessed. The grid should identify the authorized user by department and position and the limitations on access to information. If subcontractors are used for certain services (billing service, laundry, dietary, etc.), language needs to be included in the contracts outlining the employee’s responsibility to maintain resident confidentiality and their authority to access the medical record.

    Employee/Contractor Access to Medical Records


    Access to Records Granted


    Administrator/Executive Director


    No limitations

    Director of Nursing Services


    No limitations

    RAI Coordinator


    Full access to records but only residents on their case load

    Staff Nurse


    Full access to records but only residents on their case load

    Nursing Assistant


    Care plan and NAR flowsheets only

    Health Information Services


    No limitations

    Health Information Consultant


    As directed by the facility

    Business Office Manager


    Access only to clinical information required for billing purposes

    Director of Laundry


    Access only to information necessary to do job

    Laundry Staff





    Access only to information necessary to do job and only for those residents requesting pastoral services






    This table is not all-inclusive and is for discussion/illustration purposes only. Positions, access and scope should be determined by each facility. No recommendations are made through this illustration.

    A second access grid should also be developed for access to clinical information computer systems. The grid would serve the same purpose of outlining who has access to the system and what screens or programs are available to the position.

    Employee/Contractor Access to Clinical Information Computer System


    Access to System


    Administrator/Executive Director


    Billing and Clinical

    Director of Nursing Services


    Clinical Only

    RAI Coordinator


    Clinical Only

    Staff Nurse


    Clinical Only

    Nursing Assistant



    Health Information Services


    Billing and Clinical

    Health Information Consultant


    Access as directed by facility

    Business Office Manager


    Billing and Clinical

    Director of Laundry



    Laundry Staff








    Demographics Only



    This table is not all-inclusive and is for discussion/illustration purposes only. Positions, access and scope should be determined by each facility. No recommendations are made through this illustration.

    *As computer systems access control becomes more sophisticated, the scope and limitation should be more specific to the specific programs and screens in the system.

    In addition to an access grid for employees and contractors, a grid should be included which outlines access to records by other types of providers, agencies or third-party users. This grid should outline whether a release of information form is required to be signed before information is disclosed or released and when reporting/disclosure is mandatory by law. Both federal and state regulations need to be incorporated into the facility policy and procedure and access grid.

    The federal regulation (42 CFR § 483.75(4)) requires that the facility must keep confidential all information contained in the residents’ records, regardless of the form or storage method of the records, except when release is required by – (i) transfer to another health care institution; (ii) law; (iii) third party payment contract; or (iv) the resident.

    The disclosure grid should outline access by the following individuals/entities and whether an authorization from the resident is required to release information.

    *Completion of this grid should be based on state applicable state and local laws the following are guidelines

    Requestor or Outside Party

    Authorization Required

    Copy Charges Assessed

    Accrediting Agencies (JCAHO, CARF)






    Attorney for Facility/Corporation



    Courts of Law (Court Order)



    Employer of Resident



    Family members



    Federal, State, and Local Government, and Voluntary Welfare Agencies

    No – when reporting is required by law

    No – when reporting is required by law

    Funeral Homes

    No – when


    Health Department

    No - when releasing remains


    Healthcare Practitioners

    No - for continuity of care purposes when involved in residents care and treatment

    Yes – if not involved in care and treatment

    No – for continuity of care and continued treatment.

    Yes – if not involved in care and treatment

    Healthcare Providers (hospitals, LTC facilities, home health agencies, etc.

    No – for continuity of care purposes

    No – for continuity of care purposes

    Insurance Companies/Third Party Payers

    No – for third party payment purposes

    No – for third party payment purposes

    Insurance Companies for Facility/Corporation



    Law Enforcement Officials

    Dependent on state law


    Medical Examiner/Coroner

    No – if reporting is required by law



    Dependent on state law



    No – if project is approved by facility

    No – if project is approved by facility




    4.9.6 Handling a Request for Medical Records

  • Every request for healthcare information includes a valid authorization to disclose confidential resident-identifiable data and healthcare information.
  • All request for information should be handled by the health information department to assure uniform application of the facility policy and adherence to applicable laws and practice standards. When a request for information is made, the following issues should be considered before releasing information:

    • Is an authorization to release information required to be signed by the resident or their legal representative?
    • What is the nature of the information requested.
    • Is the information considered confidential or non-confidential?
    • What is the purpose of the request?
    • What is the authority of the person or agency requesting the information?
    • Are there any revocations or notices to withhold information on file?

    Consent for Use and Disclosure of Protected Health Information:
    Under the HIPAA privacy rule, the facility must obtain the resident's consent prior to using or disclosing protected health information to carry out treatment, payment, or health care operations (review the privacy rule for specifics on exceptions and requirements). Once the consent is signed, the facility may disclose information without additional authorizations for treatment purposes, to obtain payment for services, and for activities related to facility operations. Review of Authorization for Release of Information

    When a request for information is made that requires an authorization to release information, the authorization form should be reviewed to determine if it is complete. Many states have specific laws governing the content of the authorization. HIPAA also established minimum requirements for the content of an authorization form. In absence of state law requiring additional information, an acceptable authorization to release information should include all of the following:

    • Be in writing or be given via computer (facsimiles or copies may be accepted if the LTC facility’s policy allows them). Under HIPAA, the authorization must be written in plain language.
    • Be addressed to the LTC facility or the facility’s health information management professional.
    • Specifically identify the resident (the resident’s full name, address and date of birth to assure proper identification).
    • Identify the individual or entity authorized to receive the information.
    • Identify the health information authorized for disclosure (for example, specify the medical record documents and dates).
      If a request for "all medical record information" or "any and all records" is made, contact the requesting party and clarify which documents are needed. Identify the estimated number of pages and the estimated copy charges. Often the requestor has specific documents in mind to serve the purpose of the request. If all records are requested and the authorization is valid, copy and send all information.
    • Specify the date, event, or condition upon which the authorization will expire unless revoked earlier.
    • Indicate that the resident, or the resident’s legal representative, can revoke the authorization.
      The authority to grant an authorization may reside with the resident, if competent or an emancipated or mature minor; a legal guardian or parent on behalf of a minor; or the executor of the estate or an individual appointed by the probate court, if the resident is deceased.
      If the resident is incompetent or cannot authorize the disclosure, the following individuals may serve as the resident’s legal representative, in order of priority: legal guardian or attorney ad litem; agent named in a directive, durable power of attorney for health care, or other durable power of attorney; or next of kin, in the following order: spouse from a marriage recognized by law, adult son or daughter, father or mother, adult brother and sister. State law may determine this order which could vary from state to state.
    • A statement that the information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and lo longer be protected by the HIPAA privacy rule.
    • Be signed or authenticated by the resident or the resident’s legal representative (if someone other than the resident has given authorization, that individual must indicate his or her relationship to the resident or legal authority).
    • Be dated sometime following the resident’s admission. Unless state law provides otherwise, no more than six months should elapse between the date of signature on the authorization and the date the information is requested.

    Reference: Release and Disclosure: Guidelines Regarding Maintenance and Disclosure of Health Information. Mary Brandt, MBA, RHIA, CHE. Preparing a Record for Release

    All information requested and authorized must be copied. The copier should be adjusted to assure that all documentation is readable (adjust copier shading). Make sure that the resident’s name and medical record number are on every page in the record and both sides of a double sided form (such as the nurses notes). If shingled pages are used in the record (i.e. telephone order slips), each individual shingle must be copied. If the entire discharge record is requested, number the pages of the record prior to copying.

    If there is the potential for the record to be used in a legal proceeding involving the facility, the health information practitioner should notify administration and the facility legal counsel per facility/corporate policy. In many cases, it is in the facilities best interest to keep a duplicate copy of the record sent to an requesting attorney. This will provide a record for the facility’s legal counsel on what was sent for review.

    A duplicate copy of records may also be kept for records sent to the Fiscal Intermediary upon a request for medical review. The duplicate copy will provide a record of the documents used in the Medicare determination. Turn Around Time for Responding to a Request for Copies of Medical Records

    The maximum turnaround time to respond to a valid request for information accompanied by a valid authorization is 30 days unless otherwise required by state law. When a resident or their legal representative requests copies of their medical record, copies must be made within 2 working days.

    Copy Fees for Release of Information

  • A reasonable and justifiable fee structure reflects the actual labor and photocopying expenses involved in releasing resident-identifiable data and healthcare information as permitted by law.
  • In the event the resident or the representative wants a copy of the medical records, the facility is required to make copies. Facility policies should state the copy fee rates charged. The federal regulations imply that a copy fee may be charged but "at a cost not to exceed the community standard." 42 C.F.R. § 483.10(b)(ii). Some states have laws that dictate the maximum copy fees a health care provider can charge. AHIMA has published a summary of state law copy charges in a practice brief. The practice brief, "Release of Information: Laws and Regulations" is available in the AHIMA Library, the association's online body of knowledge, and at

    For those states that do not have a specific law governing copy fees, an amount not to exceed the community standard can be charged. The community standard can be determined by reviewing photocopy charges from the post office, library, or local copy center.

    Under the HIPAA final privacy rule, LTC facilities can charge a reasonable cost-based fee if the individual requests a copy of their protected health information (medical record) or agrees to a summary or explanation. The reasonable, cost-based fee can only include the cost of:

    • Copying, including the cost of supplies for and labor of copying, the medical record requested by the individual.
    • Postage, when the individual has requested the copy, or the summary or explanation be mailed; and
    • Preparing an explanation or summary of the medical record if agreed to by the individual. Documenting the Release of Information (Accounting for Disclosures)

    The signed authorization form should be retained as a part of the resident’s medical record. On the form, make a notation stating the information disclosed, the staff member disclosing/copying the information, and the date the information was sent to the requesting party.

    Facilities can also chose to maintain a release of information log to document all requests and disclosure. The log can also be used as a tracking tool to monitor incoming requests and completion dates.

    Sample Release of Information Log

    Date Received

    Requested By/Sent To:

    Resident Name:

    Information Copied/Sent & Purpose:

    Released By:

    Copy Charge

    Date Sent:


    Under HIPAA, residents have the right to request an accounting of disclosures (releases) for the previous six years from the date of the request. Facilities must start a tracking process for disclosures by April 14, 2003. The accounting does not need to include disclosures made to carry out treatment, payment and health care operations, disclosures made to the resident, or disclosures from the facility directory. The accounting of disclosures must include:

    • The date of the disclosure.
    • The name of the entity or person who received the information/records and, if known, the address.
    • A brief description of the purpose of the disclosure that reasonably informs the individual of the basis for the disclosure; or, in lieu of a statement, a provide a copy of the written authorization or written request for disclosure.

    Facilities must retain the information required for the accounting, the written accounting provided to the resident, and the titles of the persons responsible for receiving and processing the requests for an accounting.

    4.9.7 Redisclosure of Health Information

  • The healthcare organization’s and health information management department’s policies and procedures identify the circumstances that require the inclusion of a redisclosure notice with the release of resident-identifiable data and healthcare information.
  • Long term care facilities will often have records from other health care providers, such as a hospital or another nursing facility, as part of their records. Redisclosure is the process of releasing records that were provided to you from a previous facility for continuity of care purposes.

    HIPAA does not prohibit redisclosure of health information/ medical records and requires facilities to protect the privacy of records that were received from another facility. State regulations should be reviewed for any restrictions in redisclosure. Unless otherwise required by state law or regulation, AHIMA recommends the following:

    In general, health care providers should:

    • redisclose to other health care providers protected health information when it is necessary to assure the health and safety of the patient
    • redisclose requested health information to patients when necessary, but after first encouraging the patient to obtain the most complete and accurate copies from the originating healthcare provider
    • redisclose protected health information when necessary to comply with a valid consent and notice of privacy practices
    • redisclose protected health information when necessary to comply with a valid authorization or legal process

    Reference: Practice Brief - Redisclosure of Health Information (2001) Gwen Hughes, RHIA.. Redisclosure upon Transfer to Another Healthcare Facility

    If the hospital or another facility's records provide important information for the continued care of the resident, those records should be sent to the next facility/agency that will be providing care. A LTC facility should send the most recent hospital history and physical report and discharge summary upon transfer to another facility if the information provides insight into the resident’s current health status or would be beneficial in the continued diagnosis and treatment. Other documents should be redisclosed based on the content and relevance to the resident’s continued care and treatment.

    4.9.8 Handling Telephone Requests for Information

    When a request for a resident’s health information is received by telephone, the person receiving the request must decide if they have the authority to handle the request, decide whether information can be disclosed without an authorization, and verify that the individual has a right to receive the information. With the exception of requests related to the resident’s current care and treatment, telephone requests should be directed to the health information department.

    Telephone requests can be honored without an authorization if they meet the specifications in the federal regulations – when needed for a transfer to another health care institution (for continuity of care purposes), when required by law, for third party payment, or when requested by the resident (including the legal representative). The call should be returned to verify the identity of the individual requesting information if they are not known to the health information department/facility staff handling the request.

    Under HIPAA, the Consent for Use and Disclosure of Personal Health Information signed by the resident would cover telephone release in certain situations. The consent would cover requests made for treatment purposes, for payment purposes, or facility operation provided that the resident did not request a restriction.

    4.9.9 Transmitting Resident Information via Facsimile


  • Policies and procedures establish the circumstances under which transmission of resident-identifiable data and healthcare information by facsimile machine is appropriate (such as when the original document or mail-delivered photocopies will not serve the purposes of the requestor)
  • When the fax machine is used to release of transmit resident health information, safeguards must be in place to protect the resident’s confidentiality. If a LTC facility uses the fax machine to transmit information they must have a policy and procedure in place directing staff on the proper procedures.

    • A fax cover letter must always be used when sending resident information. The cover letter should indicate whom the fax is sent to, whom it is from, the number of pages, and a confidentiality statement. A facility should never send resident information (whether medical record documents or a narrative summary/notes) without a cover sheet.
    • The fax cover letter should provide specific directions on the steps to take if the fax was sent to the wrong location/person.
    • Preprogram fax numbers into the machine whenever possible to minimize the chance of entering an incorrect fax number resulting in a misdirected fax.
    • If faxing is used to correspond with the physician and a response is needed, maintain a monitoring system to assure that a response is received. If an immediate response is needed or the resident’s condition requires immediate intervention, the telephone should be used to contact the physician rather than the fax machine.
    • Some type of verification process should be in place to assure that the fax was transmitted. Verification may vary from a report generated by the fax machine to a call back from the receiving party. The type of verification used should be dependent on what was sent and who it was sent to.
    • Facility policy should outline the types of information that cannot be faxed.

    4.9.10 Responding to a Subpoena or Court Order

    It is critical that state law is followed in processing a subpoena. The following provide general guidelines in handling a subpoena when it is received. Facility policies should be tailored to specific state statutes.

    • Check that the subpoena is signed by a representative of the court (usually the Clerk of Court).
    • If a subpoena is received notify facility administration and the facility legal counsel per facility policy. Some corporate offices require that the corporate legal department be notified and approve the release before records are sent.
    • Review the entire medical record to make sure that all sections in the record are present and in the proper sequence. For a discharge record, do not make any alterations in the record or allow anyone else to make additions, corrections, or deletions after the subpoena has been received.
    • Number the pages of the record (including shingled copies), verify that the records all belong to the correct resident, and check that the resident name and medical record number are on all pages including both sides of forms. Make the requested copy after approval from administration/legal counsel if required by facility policy. Make a second copy for facility use/legal counsel.
    • If the record is for a discharge resident and for litigation purposes, the records should be removed from the storage/filing area and placed in a locked location until the litigation process is complete.
    • Deliver the copy of the record to the location listed on the subpoena.
    • Upon return from court, write a note on the subpoena identifying by whom the subpoena was answered, the date and time, the attorney’s name, and note that a copy of the medical records was left with the court.
    • If the original record is requested, contact the Clerk of Court to determine if a copy is acceptable. If the original is required for court --
      • Create a Receipt for Medical Records and keep one copy for the facility and one for the person accepting the record on behalf of the court. Include on the receipt an inventory of the medical record content. For example, nurses notes – 20 pages, physician orders – 10 pages, total pages – 30.
      • Place the original record in a folder with the receipt and label as the "Original Medical Record."
      • Deliver both the original record and the copy to the location listed on the subpoena.
      • Remain with the original record at all times until you are sworn in.
      • Request the Court Official to review the copy to see if they will accept the copy in place of the original. If the Judge or Hearing Officer refuses to accept the copy in place of the original, leave the original record. Request that the original record be returned to the facility when the case is completed.
      • Obtain a signature of the original copy of the Receipt for Medical Records from the Clerk of Court. Keep the original copy of the receipt.
      • Leave the copy of the receipt with the record held by the Court.
      • Upon return from court, write a note on the subpoena identifying by whom the subpoena was answered, the date and time, the attorney’s name, and the original of the medical records was left with the court.
      • File the subpoena and the signed receipt in the resident/resident’ medical record file folder until the record is returned.
      • After the record is returned, check the record against the receipt to make sure that all pages are present. Reassemble the record in proper order, if necessary. Note the date returned on the receipt/subpoena and file the original record in the permanent file.

    4.9.11 Removing Original Records from the Facility

  • Original health records may not be physically removed except in accordance with the healthcare organization’s policies.
  • The original medical record should never be removed from the facility. Facility policies should specifically address removal of records and prohibit any employee, contractor or agent from removing resident medical records (in full or in part) from the facility. When records are requested for legal proceedings, it is acceptable to submit a copy of the original. If the original record is specifically requested for a legal proceeding, every effort should be made to submit a copy. For example, contact the court requesting that a copy versus the original be submitted or go to court with the original record and a copy. Request that the copy be placed into evidence rather than the original record. If the original must be placed into evidence, then the copy can be used by the facility.

    If it is absolutely necessary to remove the original record, measures should be in place to physically protect the original. One possible method is to utilize the storage bags with plastic locks that can be purchased through medical record supply companies. The bag can be locked at the facility and the lock broken once at the destination. If the original record does have to be removed from the facility, it should always stay in the custody of a facility representative who takes full responsibility for its safe-keeping.

    4.9.12 Notice of Information Practices

    The HIPAA privacy rule requires facilities to provide the resident with a notice of the uses and disclosures of protected health information, the resident's rights, and the facility's legal duties. The notice should be provided before services are delivered (usually in conjunction with signing the Consent for Use and Disclosure of Protected Health Information). The notice must be written in plain language and contain the following elements: (See HIPAA privacy rule for specifics under each section)

    • Header: "This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully."
    • Uses and disclosures
    • Separate statements for certain uses or disclosures
    • Individual rights
    • Covered entity's duties (facility's duties)
    • Complaints
    • Contact information
    • Effective date
    • Other optional information as described in the HIPAA privacy rule
    If there are changes to the notice it must be promptly revised and distributed.

    4.9.13 Designation of a Privacy Officer

    HIPAA requires the designation of a privacy official who is responsible for the development and implementation of the policies and procedures of the facility related to the privacy rule. The facility must also designate a contact person or office who is responsible for receiving complaints related to the facility's privacy practices. The privacy official and contact person does not have to be the same individual. The rule does not require specific training or expertise. AHIMA has published a model position description for the Privacy Officer available in the AHIMA Library, the association's online body of knowledge, and at


  • The healthcare organization’s diagnosis and procedure coding guidelines for all resident types are based on current ICD-9-CM, CPT and HCPCS classification systems to ensure the retrievability of pertinent information.
  • The director of the health information management department supervises or monitors any diagnosis and procedure coding done outside the department to ensure the complete and accurate description of resident services.
  • The director of the health information management department (or a designee) provides training and/or consultation to staff outside the department who assign or analyze diagnoses and/or procedure code
  • The coding process in long term care facilities primarily involves the use of the ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) system for assignment of a diagnostic code to diagnoses. diseases, and conditions for a resident. ICD-9-CM coding is a key function for health information practitioners in a facility. It is critical that health information staff have adequate training and resources to accurately and completely assign diagnosis codes.

    In a long term care facility, diagnosis codes are generally assigned on the face sheet/admission record, on the diagnosis/problem list, on the MDS, and for billing purposes on the UB-92. Assignment of diagnosis codes on the face sheet/admission record and diagnosis/problem list is not mandated by regulation, but are highly recommended. Reporting codes on the MDS and UB-92 are required.

    4.10.1 Training and Resources

  • Competent, credentialed clinical coders are recruited, hired and retained.
  • Health information management employees who perform diagnosis and procedure coding functions attend educational programs related to their responsibilities, including orientation, on-the-job training, in-service education, and external educational opportunities.
  • ICD-9-CM, CPT and HCPCS coding books and computer software are updated on an annual basis as the classification systems are revised
  • Training:

    The health information practitioner in a facility should be trained on the proper use of the ICD-9-CM system. Ideally, this training should be through a formal course or program. If staff who code do not have access to a formal training course, at a minimum, they should attend a comprehensive coding workshop, have current resource materials available, and access to a trained, credentialed HIM consultant/professional for questions and clarification.

    Under consolidated billing for Medicare, CPT and HCPCS codes are utilized to reflect services and supplies. LTC facilities should have health information staff who have basic training and an understanding of the CPT and HCPCS coding system.

    Although coding should be completed by trained coders, if other staff (such as a MDS nurse, biller, or Medicare nurse) use the ICD-9-CM coding system, they should also be trained in the correct coding process, official coding rules, and standards of ethical coding.


    • Current ICD-9-CM Code Books (code books are updated each year in October. New code books or updates must be purchased). All staff who code must have access to current code books. The ICD-9-CM database used for clinical and financial computer information systems must also be updated each year either by the vendor or by health information staff.
    • Current CPT Code books (updated annually).
    • Current HCPCS code books (updated annually).
    • If staff who complete coding have not been through formal coding training, coding resource books for ICD-9-CM and CPT/HCPCS should be available. Basic coding handbooks are available through AHIMA and other coding vendors. AHIMA publishes a long term care resource for coding that will assist staff in the coding process. (Insert URL and book title)
    • The LTC facility should have a copy of the Official Coding Rules available on the Center for Disease Control website. Under the Health Insurance Portability and Accountability Act (HIPAA), LTC facilities will be required to follow the official coding guidelines for ICD-9-CM. The guidelines are available at
    • All LTC facilities should subscribe to Coding Clinic, a quarterly newsletter published by the Official Office for ICD-9-CM coding. The newsletter provides official coding advice from the Cooperating Parties which is necessary for adherence to the transaction and code set standards required by the Health Insurance Portability and Accountability Act (HIPAA). Subscription information is available at
    • Coders should be aware of and abide by the Standards of Ethical Coding available at (under AHIMA Guidelines) or in the AHIMA Library.

    4.10.2 Frequency of ICD-9-CM Coding

    As a general rule of thumb, facilities should have a process to review the record, assign new ICD-9-CM codes, and report them on the diagnosis/problem list in the following timeframes:

    Minimum Coding Frequency:

    • Admission/Readmission: Each time a resident is admitted, readmitted, or returns from a hospital stay, the physician documentation (physician orders, history and physical, physician signed transfer form, hospital records, etc.) should be reviewed and diagnosis codes reported in the medical record. The diagnoses should be coded and reported in time to be used in completion of the MDS.
    • Quarterly/Per MDS Schedule: At a minimum, the resident’s medical record should be reviewed on a quarterly basis to coincide with the MDS schedule. The physician progress notes, orders, referrals/consultation reports, etc. should be reviewed for new diagnoses or resolved diagnoses.
    • Discharge: To complete the disease index information (if one is being maintained) and have a record of all pertinent diagnoses, the medical record should be reviewed and new diagnoses coded and reported for billing and other record keeping purposes.

    Concurrent Coding:

    Health information staff can also opt to code the record on a concurrent basis. As diagnoses are added or resolved during the resident’s stay, they are coded and reported in the medical record and updated in the information system. This type of process is usually dependent on nursing staff identifying new diagnoses in physician documentation and routing the information to the health information staff for coding. Another concurrent process is to assign codes based on the physician order entry into the clinical computer system. Concurrent coding helps to assure that the medical record and information system have up to date information on diagnoses at all times.

    For documentation issues related to coding, see Section 6.8

    4.10.3 Coding and Billing Relationships

    The health information professional should be well versed and involved in the coding or monitoring process in a long term care facility and understand the link to the billing cycle. Billing staff must also recognize that accurate and complete ICD-9-CM, CPT, and HCPCS codes are necessary in accurate billing.

    The Health Insurance Portability and Accountability Act (HIPAA) contains regulations pertaining to transaction and code set standards for the health care industry. The law requires that both health care providers and payers utilize specific code sets and follow the official coding guidelines established for each code set when submitting electronic transactions (i.e. electronic billing/claim submission). Payers will no longer be able to set their own rules for reporting diagnoses that conflict with official policy.

    ICD-9-CM codes on a billing claim form usually provides information on the medical necessity of the services billed. Each code number represents a specific disease or condition for the resident that must be supported by physician documentation. An inaccurate diagnosis code used to justify services billed could potentially be considered fraudulent if the resident does not have the diagnosis used to justify the services utilized and billed.

    CPT and HCPCS codes represent services or supplies. When a CPT or HCPCS code is reported on a claim form, the facility is indicating that the specific service or supply represented by the code was provided and medically necessary. It is important that all services and supplies represented by the CPT or HCPCS codes be supported by documentation in the medical record regardless of whether it is a Medicare part A claim (where all services are lumped together under one revenue code) or a Medicare part B claim (where each item is line item billed per service and per day).

    4.10.4 Investigation of Claim Rejection/Denials due to Coding

    Communication must be established and maintained between the billing and health information staff when billing claims are rejected or denied for coding reasons. It is not appropriate for the billing staff to change the code without knowledge of the resident’s current condition just to get a claim paid. Health information staff should be consulted to determine the reason for the rejection of denial such as an invalid code, lack of 4th or 5th digits, or improper sequencing. The reason for the denial/rejection should be investigated and the resident’s record reviewed prior to resubmission. If necessary, consult with the fiscal intermediary. If requesting direction on coding, ask for coding advice in writing and keep a written log of phone calls, discussion, and recommendations. If the fiscal intermediary will not put their recommendations in writing, obtain the staff name and write a letter back to the FI summarizing the advice received. Keep a copy of the letter with facility logs.

    4.10.5 Coding Issues Under Consolidated Billing

    Under consolidated billing (both Medicare part A and part B), health information and billing staff must be concerned with the accuracy of the vendor invoices received and billed under the facility's provider number. When a vendor bills the facility for services provided to a Medicare resident, they should provide the CPT/HCPCS code and date of service. To assure accuracy, the facility should have a process to review vendor invoices prior to billing Medicare. The goal of the review process is to assure that the service or supply was provided (based on medical record documentation), physician ordered, and medically necessary.

    4.11 Indexes and Registries

    There is a minimum of three indexes or registries that every long term care facility should maintain. Indexes or registries provide baseline information in a retrievable format and are fundamental components in managing a facility’s health information. At a minimum, every long term care facility should maintain a master patient index (MPI), and an admission and discharge register.

    4.11.1 Master Patient Index (MPI)

    HIM Standard
  • The computer-based patient record system is supported by the organization-wide master patient index or other resident identification mediation service that ensures accurate and timely resident identification.
  • The master patient index (MPI) is a valuable reference for basic demographic information and resident activity (i.e. admission and discharge dates) within one source. The MPI is an index maintained separately from the resident’s medical record. It is used to identify that a resident had a stay in the facility, the dates of the stay and other important data in an easily retrievable format (i.e. alphabetically or through name searches). Maintaining an MPI

    An index can be maintained manually or as part of a computerized system. Because the information in the MPI is important for tracking resident stays in an organization, the MPI should be retained on a permanent basis. Information on the MPI should be updated with changes throughout the residents’ stay.

    Most long term care facilities maintain the MPI alphabetically. If the MPI is computerized, facility staff should be able to retrieve the information by resident name and by medical record number.

    Maintaining a Manual MPI:

    There is no required form or format for the MPI. The most common manual format for an MPI is the use of index cards. The index cards are completed on admission and updated with changes throughout the resident’s stay. The index cards are typically filed alphabetically in long term care facilities.

    Another common method for maintaining a MPI is to use a copy of the admission record (face sheet). On admission the face sheet is printed, kept updated throughout the residents’ stay and on discharge, the discharge date and disposition are documented. The face sheets are maintained alphabetically and retained on a permanent basis.

    There are a variety of methods for filing the MPI information including separating the current admissions from the discharges or integrating the current admissions with previous discharges. For facilities that have decades of MPI information, it may be necessary to separate some of the MPI cards. For example, to manage the volume of information MPI cards from the 1960’s, 1970’s, 1980’s may be separated, maintained alphabetically and filed together.

    Maintaining a Computerized MPI:

    Many computer systems have the MPI information readily available through the demographic and census program. It is not necessary to have a manual index if the information is computerized, however, it is critical that the information be available on a permanent basis. There are MPI programs available for other health care settings, but they are not commonly used in the long term care setting at this time unless the facility is attached to a hospital or part of an integrated delivery system.

    Computerized MPI information has many advantages for an organization including ease in access and retrieval. Because of current limitations in software programs available in the long term care industry, consider the following before moving to a fully computerized MPI:

    • Does your system have the capability to retain the core MPI elements on a permanent basis? If not, a manual system should be considered to back up the computerized system.
    • If you change computer systems, how will you access the MPI information in the old system? Will the new system allow for transfer of the core MPI elements from the previous software? If not, the MPI information from the previous system should be printed out and maintained manually or data entered into the new system.

    Some computer systems will have a report that allows for an MPI card or sheet to be printed. The most common reasons for printing a hard copy include:

    • Continuation of a manual system. Many facilities have decades of MPI information available in a manual format and see advantages to continuing this type of system particularly as a back up to the computerized system.
    • If resident and MPI information has to be purged from the computer system because of memory/storage limitations the MPI information should be maintained manually.
    • Manual systems are maintained when there are questions about the long term viability of the computer system and concerns that the system won’t be available for retrieval of information.

    It is possible to maintain a partially automated and partially manual MPI system. There should be a clear point in time when all MPI information is maintained in the computer system rather than manually. Proper safeguards must be in place to prevent from loss or destruction of the computerized MPI information.


    The MPI should be retained on a permanent basis to provide historical access to basic resident information and dates of stay in an organization. Minimum Content

    The content or format of the MPI may vary from health care facility. At a minimum, the MPI in a long term care facility should contain the following data elements:

    • Medical record number
    • Resident name (legal name including surname, given name, middle name or initial, name suffixes (Junior, IV), and prefixes (Father, Doctor).
    • Date of Birth (day, month, and year)
    • Gender
    • Address
    • Alias or previous name (other names patient is known including nicknames, maiden name, previous name that was legally changed)
    • Social security number
    • Admission/Readmission date(s)
    • Discharge/Transfer date(s)
    • Resident disposition (resident’s intended care setting following discharge or died)

    There are many other data elements such as attending physician, marital status, emergency contact that can be included in a facility MPI. The list provides the minimum content, but should not be considered all-inclusive. Other data elements should be added to meet the needs of the facility/organization. AHIMA has published a practice brief with additional core elements to the MPI. This practice brief, "Master Patient (Person) Index (MPI)—Recommended Core Data Elements" is available in the AHIMA Library, the association's online body of knowledge, and at

    4.11.2 Admission/Discharge Register

    An admission and discharge register (or census register) lists chronologically all admissions and discharges by date. This type of register can be maintained either manually or on a computer system. Some states require a specific format such as a bound book which continues to be the most common format used for this type of register.

    If there are multiple care settings on a long term care campus (i.e. assisted living and a long term care facility –NF/SNF), admission and discharge information should be maintained for each setting. The campus must determine if one census register will be maintained for the campus or if each setting will maintain their own register. If one is maintained, the register must clearly indicate the care setting.

    Minimum Content:

    At a minimum, the admission/discharge register should contain the following information:


  • Admission date
  • Resident name
  • Medical record number
  • Where admitted from
  • Discharges:

  • Discharge date
  • Resident name
  • Medical record number
  • Where discharged to/discharge disposition
  • Optional Information:

  • Transfer and return dates (bedhold information)
  • Pay source (on admission and on discharge)
  • Discharge length of stay
  • Attending physician
  • Register Format:

    Unless required by state law, facilities can determine the format and content of the admission/discharge register to meet their needs. This type of register can be very helpful in compiling statistical information/reports for a facility. The following are two examples of the most common formats used for recording admission and discharge activity:

  • For each month, admissions are recorded on one page/side of the register and discharges on the opposing page. Both the admissions and discharges are listed chronologically.
  • For each month, list chronologically all activity integrating admissions and discharges and sequencing them in date and time order. This method gives you a picture of the activity each day whether it was an admission or a discharge.
  • Retention:

    The admission/discharge register should be retained on a permanent basis to provide a historical record of activity in the long term care facility.

    4.11.3 Disease Index

    HIM Standard:
  • The integrity of a disease index is maintained.
  • Disease indexes are used to provide cross-reference for locating health records of all patient types for the purposes of epidemiological and biomedical studies; health services research; and statistical research on occurrence rates, ages, sex, complications, and associated conditions; as well as continuous quality improvement/total quality management activities.
  • The maintenance of a disease index may be required by state regulation. In the absence of such a requirement, the maintenance of a disease index is optional for long term care facilities. The decision to maintain a disease index should be based on facility/corporate need for diagnostic information. Disease or diagnosis information can be a valuable tool in understanding the population served by the facility, for evaluating special programs offered, or to assist with planning for the future programs such as an Alzheimer's or rehab unit. If a long term care facility decides to maintain a disease index, either a manual or computerized format can be used to provide access to diagnostic information on the resident population.


    The most common purpose for a disease index in a long term care facility is to identify or provide access to resident(s) who have a certain disease/diagnosis based on an ICD-9-CM diagnosis code.

    At a minimum, a disease index report should include:

    • Resident’s name and medical record number
    • Attending physician
    • Admission date
    • Discharge date
    • Discharge length of stay
    • ICD-9-CM diagnosis codes present during the resident’s stay. (For reporting or planning purposes, it can be helpful to identify the primary diagnosis for which treatment was received.)

    Optional Information:

    • Resident’s age or date of birth
    • Resident’s sex


    There is not a specific format required for a disease index unless dictated by state law. Either a manual or computerized index can be maintained. Forms supplies for the long term care industry have sample forms that can be used for maintaining the disease index.

    Since disease indexes have primarily been maintaining manually, the availability of reports through the clinical information system have been overlooked as a means for maintaining the index. If a clinical information system collects diagnostic information and provides reporting capabilities by resident and by diagnosis code the system may have the capability of serving as a disease index. The advantages of using a computerized system is that diagnoses are updated continually through a residents stay minimizing the need to additional staff time in maintaining the index.

    If using an automated system, the software should have the capability to report diagnoses for discharged residents as well as current residents. To get access to disease index information, the system should have the capability of searching the resident database by diagnosis code (i.e. 428.x) and by a range of diagnosis codes (801 – 899). The system should be able to identify the specific resident(s) who has been assigned the code (s) queried with a specific date range identified.


    Unless otherwise specified by state law, the recommended retention period for a disease index is 10 years.

    4.12 Minimum Statistical Reporting

    Each facility should determine their need for statistical information and the frequency in reporting. The health care data collected and reported can be very valuable in evaluating, monitoring and planning for facility operation and management.

    This section outlines statistical data commonly collected by long term care facilities – the calculation and reporting of the statistical data may be completed by various staff in the LTC facility. Typically the information is collected and reported to administration on a monthly basis. The data should also be compiled throughout the year providing year-to-date compilation.

    Statistical data should be compiled routinely and reported in a manner that allows review and analysis of the information over time (i.e. the current month and year-to-date). The use of spread sheets can be very helpful in compiling, reporting, and graphically depicting statistical data. The statistical data can be helpful to administration, the facility quality assurance/quality improvement committee, and corporate office staff.

    The following statistical formulas are shown for a monthly reporting period.

    4.12.1Total Admissions: Each month the total number of new admissions or readmission is reported. This number should not reflect residents who were out on a bed hold or temporary leave of absence.
    4.12.2Total Discharges: Each month the total number of discharges is reported excluding residents who were transferred/discharge on bed hold or left for a temporary leave of absence.
    4.12.3 Average Daily Census: To calculate the average daily in-house census in a month, add the daily census for each day of the calendar month and divide the total by the number of days in a month. Each census day begins at 12:00am and ends at 11:59 p.m. Because Medicare uses the midnight census hour as a cut-off for determining a Medicare day, this standard is generally used by the industry.

    Formula:        Sum of the Daily Census for each day of the month
                                   Total number of days in the month

    This formula can be adopted for any period of time. For example, to calculate the average daily in-house census for a year, add the daily in-house census for each day of the year and divide by the number of days in the year.

    When a resident is both admitted and discharged in one census day, they are usually counted in the daily census.

    4.12.4Total Census Days: The sum of the daily census for a given period for each day in the month.
    4.12.5 Length of Stay: To calculate the length of stay for a resident admission, total the number of days the resident has been in the facility. Count the day of admission but not the day of discharge. Typically, bed hold days or temporary leaves are not subtracted from the total length of stay for a resident.

    Average Length of Stay: The average length of stay is calculated by adding the total length of stay for each discharged resident in the month and dividing by the number of discharge residents in a month. The average length of stay can be calculated for the entire facility or by specialty unit/program. When there are short-term stay or dementia units, calculating a separate average length of stay can be helpful in accurately reporting the average length of stay for that specific population.


    Total length of stay for discharges (for facility or for a unit) in a one month period
    Number of discharges in the month

    Discharge Days or Length of Stay: The discharge days also known as the length of stay is the total number of calendar days a resident is in the facility from admission to discharge. When calculating the length of stay, count the day of admission but not the day of discharge. Days when the resident is not in the facility due to a temporary leave of absence or bed hold are not subtracted from the length of stay. If a resident is admitted and discharged on the same day, one discharge day is assigned.

    Total Length of Stay: The total length of stay is the sum of the length of stay/discharge days for a given population and discharged during a specified period. Usually the total length of stay is calculated for the entire facility, but could also be calculated by unit particularly when there are short-term or dementia units.

    4.12.6Percentage of Occupancy: The percentage of occupancy is calculated by adding the daily census for each day of the month and dividing by the total bed count days. The total bed count is the number of beds available multiplied by the number of days in the month.

    Sum of the daily census for the month
    Total bed count days in the month
    (bed count x number of days in the month)