For a nursing home record review, request the complete facility chart (including MDS assessments, care plans, MAR/TAR and CNA flow sheets), incident reports, and the records of every hospital, emergency department and hospice involved; then compare what the care plan promised with what the daily records show was done.
Nursing home charts are long, repetitive and spread across several providers. Most of the useful facts sit in the gaps between documents: a care plan that says “turn every two hours” next to a flow sheet with blank shifts, or a facility note saying “no distress” the day before a hospital records a stage 4 pressure injury. This checklist covers what to ask for and what to look for.
Records to request
Ask for the complete record for the whole stay, not only the period around the injury, because the admission baseline matters. Ask the facility to confirm in writing that the production is complete, and ask for any electronic health record audit trail if late or altered entries may be an issue.
| Record | What it includes |
|---|---|
| Admission records | Face sheet, admission agreement, history and physical, admission orders, advance directives, and the resident's condition on arrival (the baseline for everything after). |
| Physician orders and progress notes | Every order, including telephone and verbal orders, and the physician or nurse practitioner visit notes. |
| Nursing notes | Licensed nurse notes, shift notes and change-of-condition notes, including notifications to the physician and family. |
| MDS assessments | Minimum Data Set assessments (admission, quarterly, annual and significant change) with their care area assessments. Required for Medicare- and Medicaid-certified facilities. |
| Care plans | The baseline care plan and the comprehensive care plan, with every revision. Compare the interventions promised with what the flow sheets show was done. |
| MAR and TAR | Medication and treatment administration records: each dose or treatment, who gave it, and doses held, refused or missed. |
| ADL and CNA flow sheets | Bathing, toileting, eating, turning and repositioning, meal percentages and fluid intake, often charted by nursing assistants. |
| Assessments | Skin and wound assessments (including pressure-injury risk scores and wound measurements or photos), fall risk, nutrition and dietary notes, pain. |
| Weights, vitals and labs | Weight history, vital signs, blood glucose and lab results. |
| Therapy and consultants | Physical, occupational and speech therapy; pharmacist medication regimen reviews; wound care, podiatry, psychiatry and dental consults. |
| Incident and accident reports | Falls, elopements, injuries of unknown origin, altercations. Often kept outside the chart; request separately. |
| Hospital transfers | Transfer forms and the receiving hospital's emergency department, inpatient and discharge records, plus readmission paperwork back at the facility. |
| Hospice | The hospice agency's own chart: plan of care, nurse and aide visit notes, medication orders and coordination notes with the facility. |
| End of life | Death certificate and autopsy report, if applicable. |
What to look for
| Issue | Where it shows up | What to check |
|---|---|---|
| Pressure injuries | Skin assessments, TAR, turning logs, hospital admission notes | When the wound was first documented, how it progressed by stage and size, whether the care plan changed, whether repositioning was charted |
| Falls | Fall risk assessments, incident reports, nursing notes, care plan | Whether risk was identified, whether interventions were in place, whether the care plan was updated after each fall |
| Weight loss and dehydration | Weights, meal percentages, intake records, dietary notes, labs | Significant weight change, how quickly it was noticed, and whether the physician and dietitian were told |
| Medication issues | MAR, physician orders, pharmacist reviews | Missed or held doses, as-needed psychotropics without a documented reason, orders not carried out |
| Change in condition | Nursing notes, vitals, physician and family notification entries | How long between the first sign of decline and notification or transfer |
| Documentation integrity | All records, EHR audit trail | Identical entries shift after shift, late entries, charting on days the resident was in the hospital |
Putting it together
- Build one timeline across the facility, hospital and hospice records, so a transfer and the days before it read in order.
- Keep the facility's own words. Quote key entries exactly, cited to the page, rather than paraphrasing them.
- Mark gaps: shifts with no charting, missing MDS assessments, care plan reviews that didn't happen.
- Separate facts from conclusions. Whether care fell below the standard is a judgment for a qualified reviewer, and it's stronger when it rests on a clean factual timeline.
- Public inspection reports (for example on CMS Care Compare) can point to problems worth looking for in the chart, but they aren't the resident's record.
How Zicron helps
Zicron turns the facility chart, hospital and hospice records into one timeline, each entry cited to its page, with a one-to-two-page case summary on top. Handwritten or poorly scanned pages that can't be read reliably are flagged instead of guessed. The work is medical facts only: no standard-of-care or causation opinions. The price is $450 per case for up to 500 pages, then $0.50 per additional page, with a 48-hour turnaround from a complete record set. The first case is half price. Nursing home charts are often long, so ask for a firm quote on your page count first.
See a sample chronology (a fictional case). Nursing-home firms can start at /medical-chronology; legal nurse consultants at /lnc.
Frequently asked questions
- What records should I request in a nursing home case?
- The complete facility chart (admission records, physician orders, progress and nursing notes, MDS assessments, care plans, MAR and TAR, ADL and CNA flow sheets, skin, fall and nutrition assessments, weights and vitals), incident reports, and the records of every outside provider involved: hospitals and emergency departments the resident was transferred to, hospice, pharmacy, therapy and outside physicians.
- What is a MAR in a nursing home record?
- The medication administration record: the log of each scheduled and as-needed dose, who gave it and when, and doses held or refused. Its companion, the treatment administration record (TAR), logs treatments such as wound care. Blank boxes, repeated held doses and as-needed psychotropics without a documented reason are worth a closer look.
- Are nursing home incident reports part of the medical record?
- Often not. Many facilities keep incident and accident reports outside the chart and may claim they are privileged quality-assurance documents. Request them separately; whether they are discoverable depends on your jurisdiction, so your attorney will decide how to pursue them. The chart itself should still document the event, the assessment and who was notified.
- Why do hospital and hospice records matter in a nursing home case?
- They are independent records of the resident's condition. A hospital admission note that describes a stage 4 pressure injury, dehydration or a fracture can be compared with what the facility charted in the days before the transfer. Hospice is a separate provider with its own chart and plan of care, so its records have to be requested from the hospice agency.