This is the thirty-sixth in a series of articles intended to demystify retirement living options.

The last several articles in this series described some of the sorts of problems that can arise in even well-run assisted living or skilled nursing facilities. How can you tell if your friend or relative is subject to errors or oversights in care? A good first step is to read their medical chart. To do that, you need legal authorization.

A lawyer should draw up the document(s). Ideally, your loved one has taken this step long before moving into assisted living or skilled nursing. Once the document(s) have been provided to the care facility, you can ask to read their chart.

Arizona law says that an assisted living resident’s record must be “available for review by the resident or the [resident’s] representative during normal business hours or at a time agreed upon by the resident and the manager.”

A nursing home resident’s medical records must be available for review “within one business day of the resident or the resident’s representative’s request,” and you may obtain a copy to keep within two business days, although you might have to pay for the copying.

Be prepared for some nervousness on the part of the management, and be unfailingly cordial. They tend to assume that anyone who asks to see medical records intends to sue. You may be able to reduce the tension by saying something like, “As my mother’s health care representative, I feel a responsibility to understand her medical records so that I can ask intelligent questions and make informed decisions.”

The first time you read your friend’s or relative’s medical record, ask that a staff member give you a tour of the document, which may be a three-ring binder with dozens of tabs. If the document is on a computer, the same request is relevant.

The chart will typically contain some basic information about the resident; an advance directive and/or living will; a DNR (Do Not Resuscitate) order if the individual has signed one; a list of medicines and the doses that the resident is taking; doctors’ notes from periodic (often monthly) exams; nurses’ notes; summaries of any specialists’ consultations; notes from other professionals or departments, such as a social worker, a dietician, and an activities coordinator; medical test results; summaries of any physical therapy or other treatment; summaries of quarterly care planning conferences attended by representatives of all key areas providing services to the resident; any doctors’ orders not included in another section; and so forth.

One section of the chart in nursing homes is typically labeled MDS. It includes a very lengthy and detailed document called the Minimum Data Set, which is generally required by Medicare even though Medicare typically doesn’t pay for long-term care (nursing/skilled nursing) except for a short period under very limited circumstances.

It covers an extremely extensive array of topics such as hearing, vision, comprehension, mental acuity, memory, mood, behavior, preferences for daily routine and activities, ability to bathe, dress, use to toilet, eat, walk, control bowels and bladder, etc. It also reports information about any and all diseases or conditions including pain; any recent falls; broken bones; any difficulty swallowing; percent of typical meal actually eaten; condition of teeth; skin conditions including bed sores; medicines and other treatments, etc.

Once you know what sorts of information can be found in the chart, take these steps:

  1. Understand that you must not, under any circumstances, either write in the chart or remove anything. Have a pen and paper for taking notes, and sticky notes for flagging pages you have questions about.  
  2. Read the chart from front to back.  
  3. Take notes about anything that surprises or concerns you, that seems incorrect based on your knowledge of the resident, that is illegible, or that seems to conflict with the information on a different page. Jot down where the information appears so that you can find it again. 
  4. Ask the person helping you with the chart to explain any of these surprises or discrepancies.
  5. If they cannot answer your questions on the spot, make note of any follow-ups agreed to, including when you will hear back and from whom.

-- Next -- 117. Care Planning Conferences in Skilled Nursing Facilities