Your Right To Nursing Home Records

A significant portion of my professional life is spent obtaining and reviewing medical records—including nursing home records.  Obtaining medical records, whether they be from a hospital, doctor’s office, or nursing home can be a trying, confusing, and expensive exercise.  In future posts we will exam some of the intricacies of obtaining medical records from hospitals and doctor’s offices, but here I want to share a law that is underutilized despite helping to ease some of the headaches associated with obtaining nursing home records. 

As I have previously written about, there are federal laws applicable to nursing homes that accept federal funds as a part of their operation (e.g., Medicare).  One of these laws is 42 CRF 483.10, which is a provision outlining specific Resident Rights.  I would encourage anyone going into a nursing home or with a loved one in a nursing home to review this part of the law so that you know what rights exist.  In the future, we will examine several of the rights contained in this provision, but for the purpose of this post I want to focus on a resident’s right to access his or her medical records. 

The relevant portion reads as follows:

(1) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under section 1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident’s stay. Receipt of such information, and any amendments to it, must be acknowledged in writing;

(2) The resident or his or her legal representative has the right—(i) Upon an oral or written request, to access all records pertaining to himself or herself including current clinical records within 24 hours (excluding weekends and holidays); and (ii) After receipt of his or her records for inspection, to purchase at a cost not to exceed the community standard photocopies of the records or any portions of them upon request and 2 working days advance notice to the facility.

(3) The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition

42 CFR 483.10(b)(1)-(3).  In other words, you have the right to review the nursing home’s medical records within 24 hours and have the nursing home explain to you in plain English what is contained therein.  Additionally, within 2 days you have the right to obtain copies of the records of interest (though there will be a cost associated with making those copies).  This can be a particularly effective method of obtaining nursing home records if you have an attorney.  An attorney experienced in nursing home litigation knows what records should be contained in a resident’s chart and by going to the nursing home to review the original can determine if there are types of records missing.  Alternatively, it is not uncommon for nursing homes to want to avoid having attorneys on the premises and will propose simply providing a copy of the records to the attorney in a timely manner—meaning days instead of weeks.

If you are concerned about the care you or a loved one is receiving at a nursing home make sure you know your rights.  Sometimes looking at the medical chart may be the only way to better understand what is going on.  The resident or a legal representative have the right to review the medical chart at the facility within 24 hours.  -Ryan