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Medical Record Thinning Guidelines Cheat Sheet by

Thinning the Medical Record
guidelines     emr     chart     helathcare     thinning

Introd­uction

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.

Identi­fic­ation and Admission Docume­ntation

Chart Form
Guid­eli­nes
Admission Record­/Fa­cesheet
Current Facesheet
Pre-ad­mission Screening (PASARR)
Most Current
Preadm­ission Assess­men­t/I­ntake
3 months after admission
Admission Agreement (new agreement not required on readmi­ssion after temporary discharge with return antici­pated)
Financ­ial­/Ad­min­ist­rative file
Admission Consent
Permanent

History / Physical / Hospital Records

Chart Form
Guid­eli­nes
H&P
Most Current
Hospital Discharge Summary
Most Current
Hospital Transfer Form
Last Hospital Stay
Other Hospital Records (All hospital records received should be retained as part of the facility clinical record)
Retain pertinent records for 1 month after hospit­ali­zation & then thin
Immuni­zation Records
Permanent

Advance Direct­ive­s/Legal Documents

Chart Form
Guid­eli­nes
CPR Directive
Most Current
DNR Order from physician
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

Rehab Nursing

Chart Form
Guid­eli­nes
Rehab Screen
Most Recent
Rehab Nursing Assessment
Most Recent
Progress Notes/­Tre­atment Records
3 months

Activities (Thera­peutic Recrea­tion)

Chart Form
Guid­eli­nes
Progress notes
6 months to 1 year
Assess­ments
Most Recent

Dietary (Nutrition Services)

Chart Form
Guid­eli­nes
Progress notes
6 months to 1 year
Assess­ments
Most Recent

Social Service

Chart Form
Guid­eli­nes
History
Permanent
Progress notes
6 months to 1 year
Assess­ments
Most Recent
 

Clinical Assess­ments

Chart Form
Guid­eli­nes
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
(At a minimum, retain most recent assessment plus one previous)

Minimum Data Set and Care Plan

Chart Form
Guid­eli­nes
MDS
15 months readily available
Care plan
Current plan
Specialty Care Plans ie: hospic­e/d­ialysis
Current plan
Care Plan Signature Records
Current plan
Care plan recap (if used)
Current plan

Physicians Orders

Chart Form
Guid­eli­nes
Monthly 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 & Profes­sional Progress Notes/­Con­sults

Chart Form
Guid­eli­nes
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

Chart Form
Guid­eli­nes
Nursing Notes
3 months
Interd­isc­ipl­inary Notes
6 months
Nursing Summary Forms/­Flo­wsheets
3 months

Medica­tion, Treatment and Other Flowsheets

Chart Form
Guid­eli­nes
Monthly Medication & Treatment Records
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

Chart Form
Guid­eli­nes
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)

Chart Form
Guid­eli­nes
Therapy Evaluation
Most Recent
Therapy Certif­ica­tio­n/R­ece­rti­fic­ation
3 months
Progress Notes
3 months
Discharge Summary
Most Recent
Therapy Screen
Most Recent
*Once therapy is discon­tinued thin therapy inform­ation for that discipline except the evaluation and discharge summary.

HIPAA Documents

Chart Form
Guid­eli­nes
HIPAA Requests
Most Current
Accounting of Disclo­sures (if applic­able)
Most Current
Requests for Amendment
Most Current
Requests for Altern­ative Commun­ication
Most Current
Requests for Restri­ction of Access to PHI
Most Current
HIPAA Complaints
Most Current
Request to Opt Out of NPP practices
Most Current
Author­ization to Use and/or Disclose Protected Health Inform­ation
Most Current

Miscel­lan­eou­s/Legal

Chart Form
Guid­eli­nes
Clothing list or Inventory List (If required)
Most Current

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