Are your resident charts getting too heavy to handle? Residents often live in assisted living and residential care communities for many years, and as time goes by the number of assessments, physician orders, narrative entries, and other chart documents can start to become overwhelming.
To keep things manageable and easy-to-use it is a good idea to adopt a policy of “thinning,” or archiving, your resident records on a regular basis. This doesn’t mean that you simply throw things away, but rather that you move older items to an archive area and keep only the more current documents in the resident’s chart. Here are a few things to keep in mind when thinning resident records:
1. How Often?
Your policy should clearly indicate how often the charts are to be thinned. Annual or semi-annual are common practices. Following a clear policy means everyone always knows how far back a chart goes, such as the past year, past two years, etc.
2. Don’t “Thin” Everything
Some documents should remain in the current chart no matter how old they are; such as advance directives, insurance cards, etc. Most archival policies will indicate that only certain sections of the record are to be thinned, such as the narrative entries, physician orders, and medication records. Make sure important documents and information are always accessible.
3. Don’t Throw Things Away!
Once again, “thinning” a chart does not mean that documents are discarded. Establish a secure storage area with an archive file for each resident. A secure file cabinet in the administrator’s office is a good location. Follow state regulations and the advice of your legal counsel regarding how long to keep records.
Hopefully this tip will help you keep your records manageable and your binders a little lighter!