MEDICAL RECORDS 35-02-004

CHART ASSEMBLY OF ACTIVE MEDICAL RECORDS

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires that each of the New Jersey
Veterans Memorial Homes (VMH) establishes a uniform Medical Record, assuring all forms and
documents are arranged in a consistent manner throughout the VMH facility.

PURPOSE.

This policy and procedure serves to ensure that each of the New Jersey Veterans Memorial
Homes implements a medical records filing and chart assembly system that ensures all forms and
documents within the Medical Record are systematically organized and readily available in
accordance with N.J.A.C. 8:39-35.2 forms retention requirements.

PROCEDURE.

A. The Medical Record shall be divided into sections with the indicated forms that follow
filed behind each section.

Top Sections Binder--Resident I.D. picture in inside pocket.

Admitting Record

Admission Records Nursing History and Evaluation

Nutritional Assessment Form
Recreation Initial Interview Form
Ombudsman Release Form

History and Physical Current Physical

Original Physical (done on Admission)
Medical Plan of Care
Re-certification and Review of Plan Care
Abnormal Involuntary Movement Scale (AIMS)
Folstein Mini-Mental Exam (as needed)
Medication Consent Form

Physician's Orders Physician Order Sheets (ensure any

written carbon copies are sent to
Pharmacy)

Physician Progress Notes Physician Progress Notes

Primary Physician 30-Day Assessment and
Medical Plan of Care (POC)
Dietary Progress Notes
Dietary Communication Slips
Activities Progress Notes

Interdisciplinary Team Notes Interdisciplinary Team Progress Notes

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CHART ASSEMBLY OF ACTIVE MEDICAL RECORDS

Nurse's Progress Notes On-going Nurse's Notes relative to

affairs of patient care (including
Nursing Summaries)
Assessment of Decubitis Ulcer Potential
Assessment of Bowel and Bladder Training
Assessment for Restorative Nursing Care
Care Record and Restraint Check Records

Vital Signs Clinical Chart

Vital Sign Flow Sheet
Intake and Output Record
Seizure Record

Medication and Treatment Medication and Treatment Records

Insulin Control Sheets
Release of Pass Medications

Lab and Special Reports Lab, X-Ray, EKG slips/reports

Immunization Record

Rehabilitation and Therapy Physical Therapy Reports

Occupational Therapy Reports
Speech and Audiology Reports

Consultations Consulting Pharmacist Flow Sheet

Miscellaneous Consultant Reports
Psychiatric Reports
Dental Reports
Podiatric Reports

Social Service Social Service Records

Miscellaneous Electrical Appliance Safety Check

Receiving and Inventory Report
Sign Out Sheets for Residents
Inter-Disciplinary Behavior Log
Activities Attendance Record
Consent, Authorization and Release Forms
Release of Responsibility for Leave of Absence
Transfer Forms
Clothing Inventory
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CHART ASSEMBLY OF ACTIVE MEDICAL RECORDS

Care Plans Health Care Plans (Nursing, Activities, Social Services,

Dietary, Physical Therapy and Occupational Therapy)
Case Conference Attendance Roster
Resident Biographical Data Form
Case Conference Evaluation Form

1. Known allergies and sensitivities must be written on a label on the chart cover.

2. Provide a note in back of chart indicating when, who, and where purged portions
of the chart can be located.

B. Upon the admission of a resident, the Medical Record will be organized in the following
format: (*) denotes if applicable to the resident.

LOCATION/TAB RETENTION TIME

ADVANCE DIRECTIVE/ LIVING WILL/ POA PERMANENT

1. ADMISSION RECORDS

Admission/Discharge Record PERMANENT

*Admission Information Face Sheet PERMANENT
Discharge Planning (admits prior to 07/2003) PERMANENT
Medical Information or 10-10 Forms PERMANENT
Restrain Use Policy PERMANENT
Privacy Act – Health Care Records PERMANENT
VA Consent for Medical Records Release (VA10-5345) PERMANENT
Medical Consent for Treatment/Admission PERMANENT
Health Insurance Information (copy of insurance cards) PERMANENT
Consent to be Photographed PERMANENT
Resident Certification Sheet PERMANENT
Barber/Hairdresser Consent Form PERMANENT
Ombudsman Release Form PERMANENT

2. HISTORY/PHYSICAL

Comprehensive Medical Exam (admission) PERMANENT

Comprehensive Medical Exam (yearly) ONE YEAR
Medical Plan of Care PERMANENT

3. PHYSICIAN’S ORDERS

Physician’s Orders – (white pre-printed and yellow

sheets for the same month filed together) THREE MONTHS
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CHART ASSEMBLY OF ACTIVE MEDICAL RECORDS

4. INTER-DISCIPLINARY PROGRESS NOTES

Medical Update PERMANENT

AIMS Report MOST CURRENT
Vaccine Consent PERMANENT
Admission Inter-Disciplinary Progress Note (Nursing) PERMANENT
Inter-Disciplinary Progress Notes THREE MONTHS

5. VITAL SIGNS

Neuro Check Sheet THREE MONTHS

Vital Signs/Pain Intensity Scale SIX MONTHS

6. NURSES NOTES

Resident Summary SIX MONTHS

CNA Care Sheet SIX MONTHS
Diabetic Control Sheet THREE MONTHS
Intake/Output Record ONE MONTHS
*Bowel/Bladder Log – 7-days on admission
5-days on return from
external transfer FIFTEEN MONTHS
*Bowel/Bladder Log Management Plan FIFTEEN MONTHS
Pressure Ulcer Record SIX MONTHS
Daily Pressure Ulcer Log SIX MONTHS
Stasis Ulcer Record SIX MONTHS
Skin/Wound Log SIX MONTHS
Orthopedic Check Sheet THREE MONTHS
Physical Restraint Committee Review THREE MONTHS
Physical Restrain Record THREE MONTHS

7. CARE PLANS

MDS Admission Face sheet FIFTEEN MONTHS

Minimum Data Set (MDS) FIFTEEN MONTHS
RAP Modules FIFTEEN MONTHS
Pain Assessment FIFTEEN MONTHS
Braden Scale FIFTEEN MONTHS
Risk for Falls Assessment FIFTEEN MONTHS
Incontinence Review Sheet FIFTEEN MONTHS
Quarterly Assessment FIFTEEN MONTHS
Resident Status Sheet FIFTEEN MONTHS
Inter-disciplinary Note FIFTEEN MONTHS
MDS Tracking Form FIFTEEN MONTHS
Inter-disciplinary Care Plans FIFTEEN MONTHS
Nursing Assessment (admission, 3 pages) PERMANENT
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CHART ASSEMBLY OF ACTIVE MEDICAL RECORDS

8. MEDICATION/TREATMENTS

Drug Regimen Review Record ONE YEAR

*Psychotropic Consent Form PERMANENT
*Psychotropic Medication Reduction Program Report ONE YEAR
Licensed Personnel Signature Sheet PERMANENT
*Psychotropic Monitoring Sheet THREE MONTHS
*Pain Intensity Flow Sheet THREE MONTHS
Medication Administration Sheets THREE MONTHS
Treatment Administration Sheets THREE MONTHS

NOTE: Psychotropic Monitoring and Pain Intensity Flow Sheets will be filed in this
order with the corresponding MAR/TAR for that month.

9. LAB AND SPECIAL REPORTS

Admission Labs PERMANENT

Yearly Labs ONE YEAR
Semi-Annual Labs SIX MONTHS
*Monthly Labs SIX MONTHS
*Weekly Labs SIX MONTHS

10. EKGS

Admission EKG PERMANENT

EKG Reports (minimum of two regardless of date) ONE YEAR
*Pacemaker Reports ONE YEAR
*Cardiac Echo ONE YEAR
*Cardiac Ultrasound ONE YEAR

11. X-RAYS

Admission Chest X-Ray PERMANENT

Chest X-Ray (minimum of two regardless of date) ONE YEAR
*Video Swallow ONE YEAR
*Colonoscopy, EGD ONE YEAR
*All other Ultra Sound Exams other than Cardiac ONE YEAR

12. REHABILITATION AND THERAPY

*Rehabilitation Consent Form PERMANENT

*Plan of Treatment (HCFA700) PERMANENT
*Updated Plan of Care – Re-certification (HCFA 701) ONE YEAR
*Weekly Progress Notes - Physical Therapy SIX MONTHS
*Weekly Progress Notes – Occupational Therapy SIX MONTHS
*Interdisciplinary Therapy Screening Form ONE YEAR
*DRT Daily Report SIX MONTHS
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CHART ASSEMBLY OF ACTIVE MEDICAL RECORDS

13. RECREATIONAL THERAPY

Activities Admission Assessment PERMANENT

*Activities Re-Assessment TWO YEARS

14. CONSULTS

*Consults other than Dental, Podiatry, Eye, Ear ONE YEAR

Dental Consults SIX MONTHS
Podiatry Consults SIX MONTHS
Ophthalmology Consults SIX MONTHS
Audiology Consults SIX MONTHS

15. SOCIAL SERVICES

Admission Psychosocial Assessment PERMANENT

Social Service Referrals THREE MONTHS
Admission Mandatory Rights PERMANENT
Mandatory Rights Update MOST RECENT
*Referral to Special Needs Unit PERMANENT

16. DIETARY

Admission Nutritional Assessment PERMANENT

Nutritional Assessment ONE YEAR

17. *HOSPICE

All Admission Paperwork other than Interdisciplinary

Progress Notes PERMANENT

18. MISCELLANEOUS

Hospital Discharge Information MOST RECENT

Clothing Inventory PERMANENT
*Certificate of Responsibility ONE MONTH
Resident Transfer Form (original admission) PERMANENT
*Transfer Sheet – Internal SIX MONTHS
*Transfer Sheet – External SIX MONTHS
*Correspondence SIX MONTHS

*NOTE: When thinning the Medical Record, the current month is NOT included in the time frame
mentioned. For example, Physician Orders are to be retained in the Medical Record for a period of
three months and thus if the present month is April, you would keep March, February and January
on the open record. December and back would be thinned from the Medical Record and placed in
the over-flow file.
Revised: April 2010