Gaining Access to a Resident’s Records
Title 42 of the Code of Federal Regulations (Vol. 3, Public Health) contains Sec. 483.10 Resident Rights. You can easily find a complete reference to it by searching online (Google or Yahoo). Simply type “42CFR483.10” into the search box.
Sec. 483.10 sets forth the legal rights of all residents of long-term care, including language that applies to, a) a resident’s right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility, b) the right to exercise their rights without interference, coercion, discrimination or reprisal, and c) the right of a resident’s legally appointed person/representative to exercise those rights.
As it applies to a resident’s medical records, Sec. 483.10 states that a resident or his/her legal representative has the right of access to all records, including current clinical records within 24 hours (excluding weekends and holidays) of an oral or written request.
Furthermore, after examination of the records, a patient or their legal representative may purchase (at a cost not to exceed the community standard) photocopies of the records upon request within two (2) days notice.
To eliminate delays or questions regarding the right of a family member to access medical records on behalf of their loved one, it’s vital that prior to admission (or as soon as possible if admission has already occurred), that residents establish a Healthcare Power of Attorney in which a family member or trusted individual is named as their legal representative. This is true even if the resident has all mental faculties intact and can, at present, make decisions for themselves. Emergencies can, and do occur.
Ensure that a copy of the Healthcare Power of Attorney is on file (in the resident’s chart at the facility), and keep a copy on hand (easily accessible if necessary), as well as in a safe deposit box or other fireproof environment.
While there are many occasions in which access to a resident’s medical record may be necessary, there are benchmark indicators for which review (and copies in most cases) should be requested, including, but not limited to the following:
- Following the initial medical assessment and care plan development, post admission – request a copy of both the medical assessment and care plan, as well as a list of medication to be administered.
- Prior to requesting a new medical assessment and care plan if you suspect physical and/or mental changes – request copies
- Following an updated medical assessment and change to the care plan – request copies.
- At the time of any noticeable change of physical strength or mental alertness, or loss of appetite if a new medical assessment and care plan is not performed. Check for new medications and ask for a printed list of all medications being administered.
- Evidence of bed sores, pressure sores or prolonged/recurring infection (such as urinary track infections or pneumonia)
Immediately following any evidence of a fall or injury (bruising, lacerations). Often times a medical record will indicate prior falls or injuries that family members were never notified of. The cause can be traced to new medication, changes in dosage to an existing medication, lack of proper assistance due to short staffing, and sadly, intentional abuse. If you suspect abuse, notify law enforcement immediately.
If you feel intimidated in any way upon requesting inspection of a family member’s medical record, obtain assistance from an attorney experienced with skilled nursing and long-term care facilities. An experienced nursing home neglect attorney is intimately familiar with all pieces of a medical record that should be present and accounted for, ensuring that a complete medical record has, in fact, been provided to you.