Records and reports – Ohio Admin. Code 3701-17-19

Every nursing home must maintain an individual medical record for each resident, started immediately upon admission and containing the following information:

• An admission record containing the patient’s name, residence, age, sex, race/ethnicity, religion, date of admission, the name and address of his nearest relative or guardian, admission diagnoses from his referral record and the name of his attending physician; 
• A referral record containing all records, reports, and orders that accompany the resident;
• Nursing/Care notes describing the condition of the resident on admission and subsequent notes as indicated to describe changes in condition, unusual events or accidents; 
• A medication administration record;
• Resident progress notes, concerning changes in diagnosis or condition of the resident as well as resident refusal of treatment and services; 
• A resident assessment record;  and
• The resident’s plan of care.

Each medical record must be maintained for seven years following the date of the resident’s discharge; if the resident is a minor, the records must be maintained for at least three years past the age of majority, but no less than seven years total.  The nursing home must safeguard the records and reports against loss, destruction, or unauthorized use and must store them in a manner that protects and ensures their confidentiality.  

Should the nursing home close, the operator must provide and arrange for the retention of records and reports in a secured manner for no less than seven years.  

Upon request, the nursing home must provide the resident or his legal representative access to his medical and financial records and reports and photocopies of any records and reports, or portions thereof, at a cost not to exceed the community standard for photocopying.

All records must be made available for inspection at times when requested by the director of health or his authorized representative.  The records must be maintained by any method that assures that a true and accurate copy of the records is available.