Regulatory

AHIMA Medical Record Guidelines Form

AHIMA COMMON MEDICAL RECORD GUIDELINES
(AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION)

Identification and Admission Documentation

  • Admission Record/Facesheet
  • Pre-Admission Screening (PASARR)
  • Pre-Admission Assessment/Intake
  • Admission Consent Permanent
  • Admission Agreement

History and Physical and Hospital Records

  • H&P
  • Hospital Discharge Summary
  • Hospital Transfer Form
  • Immunization Records 
  • Other Hospital Records (All hospital records received should be retained)

Advance Directives/Legal Documents

  • CPR Directive
  • Resident Self Determination Act Acknowledgement.
  • Living will
  • Advance Directive
  • Durable Power of Attorney
  • Guardianship/Conservator
  • Legal incapacitation
  • Consent to Treat, Consent to Photograph, MDS Consent, MDS Acknowledgement, Release of Information Consent, Release of Responsibility/Leave of Absence)

Clinical Assessments

  • Nursing Assessment
  • Wound and Skin Assessments
  • Fall Assessment 
  • Wound and Skin Assessments
  • Bowel and Bladder Assessment
  • Pain Assessment
  • Mini-Mental/Cognitive Exam
  • Restraint Assessment

Minimum Data Set and Care Plan

  • MDS
  • Care plan
  • Specialty Care Plans, e.g., hospice/dialysis
  • Care Plan Signature Records (if used)

Physicians Orders

  • Computerized Recaps or Renewals
  • Telephone Orders
  • Interim orders
  • Protocols or Standing Order Policies (if used)
  • Fax Orders

Physician and Professional Progress Notes/Consults

  • Physician Progress Notes
  • Cumulative Problem/Diagnosis List
  • Annual Exams
  • Other specialists/consultation
  • Dental Progress Notes/Exams
  • Podiatry Progress Notes/Exams
  • Psychological Evaluation

Nursing Notes/Interdisciplinary Notes

  • Nursing Notes
  • In Nursing Summary Forms/Flowsheets 
  • Interdisciplinary Notes
  • Medication, Treatment and Other Flowsheets
  • Vitals Sign Record 
  • Monthly Medication and Treatment Records
  • Weights Record
  • Intake and Output Records
  • Behavior Monitoring Records
  • Other Flow Sheets (Diabetic site rotation, etc)
  • Pharmacist/Drug Reviews Recommendations

Lab, X Rays, and Special Reports

  • Lab Reports (frequently ordered)
  • Annual or interim Lab Reports
  • Special Diagnostic Tests 
  • X-Ray Reports

Rehabilitative Therapy (PT, OT, SLP)

  • Therapy Evaluations
  • Therapy Certification/Recertification
  • Progress Notes
  • Discharge Summary
  • Therapy Screens

Rehabilitation Nursing

  • Screen
  • Rehabilitation Nursing Assessment
  • Progress Notes/Treatment Records

Social Service, Dietary (Nutrition Services), and Activities

  • History
  • Progress notes
  • Assessments

Miscellaneous

  • Clothing List or Inventory List

http://bok.ahima.org/Pages/Long%20Term%20Care%20Guidelines%20TOC/Practice%20Guidelines/Maintenance