State regulations vary on what must be kept in a resident’s record in an assisted living community, but typically it includes a combination of resident care information (e.g., assessments, medication records, narrative notes, etc.) and financial/legal information (e.g., the residency agreement). Because of this, many providers choose to keep two separate records for each resident: one for resident care information, and another for financial information.
The biggest benefit to keeping two separate records is limiting access to financial information. The financial record (sometimes called a business file) can be stored in an area accessible only to those that are involved in billing and payments (such as the administrator’s office). This prevents caregivers and outside professionals from viewing potentially sensitive financial data.
Here are some examples of what would be retained in each record:
The “Resident Care” Record
– Admission and ongoing assessments
– Service/care plans
– Medication records
– Physician orders
– Narrative charting entries
– Vital signs records
– Miscellaneous other resident care information
The “Business File”
– The signed copy of the residency/admission agreement
– Financial records, such as invoices, payment receipts, etc.
Two resident records may not be ideal for everyone, but the benefit of securing financial information is worth considering. Be sure to check your state regulations for any further requirements regarding resident records.