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Regulations Update

Marci Pederson, RN, BSN, Nurse Educator/Consultant

Federal Regulation F514

"Clinical Records"

South Dakota long-term care facilities had 18 deficiencies cited for F514 in 2010. It ranks number 8 in the top twenty deficiencies for long-term care facilities in South Dakota.

The regulation F514 states,

"(1) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are:

    • Complete
    • Accurately documented
    • Readily accessible
    • Systematically organized

      483.75 (l)(5)

      The clinical record must contain:

        • Sufficient information to identify the resident
        • A record of the resident's assessments
        • The plan of care and services provided
        • The results of any pre-admission screening conducted by the State
        • Progress notes."

          While contemplating this update, I had writer's block; this was rather ironic since this regulation is about documentation in the clinical record. I was struggling, and then I remembered one morning in late August:

          It was 7:00 a.m. The sun was rising over the golden, green corn field to the northeast of our house. There was the rhythmic sound of sprinklers keeping the sod wet that we had laid in the backyard, taking part in an orchestra of sounds. Our dog was doing his morning rounds of the area, nose to the ground, eager to pick up any unusual smells. I had just poured myself a cup of coffee and was sitting on the patio with eyes on the luminous corn field, when I heard the sound of honking to the west-it was a flock of 12 geese, noisily announcing their arrival. They flew low around the north side of our pine trees, making a right turn in their flight pattern over the sun bright corn field, honking their "good mornings" as they continued to fly on south over the pasture across the road. I felt like I was eavesdropping on nature - a moment's gift from God. Fall had arrived.

          As I thought about this particular morning, I realized no one would know about this unless I put it into words, attempting to paint a picture. I was so captivated by what was occurring in that moment, I did not even think about trying to capture it in a picture. Had I tried, I would have missed the moment. As it is, I can still see it clearly in my mind's eye.

          Why share this? It certainly isn't documentation about a resident, but it is in a sense a progress note about nature's symptoms that point to the change of seasons. Would I see these symptoms everyday and need to write about it? There is no set time schedule where nature is concerned. With clinical records, the Guidance to Surveyors states, "there is no 'right' frequency or format for 'reporting' progress, there is a unique reporting schedule to chart each resident's progress in maintaining or improving functional abilities and mental psychosocial status". We need to be more concerned with whether or not the staff has sufficient progress information to work with the resident and less concerned with how often that information is gathered.

          Essentially, documentation should provide a picture of the resident's progress, including response to treatment, change in condition and changes in treatment. Each facility determines how frequently documentation of an individual's progress takes place apart from the annual comprehensive assessment, periodic reassessments when a significant change in status occurs and quarterly monitoring assessments. Good practice indicates that the clinical record should document change toward achieving care plan goals based on functional and behavioral objectives. It is a little like eavesdropping on the resident's whole experience in the health care facility, and it could be like nature's little God moment, only bigger.

          The regulation of F514 contains a broad outline that provides us with guidance in the process of maintaining clinical records. When we put F514 with the connections and relationships of the team with the resident at the center, it becomes the resident's story or journey in the health care facility.

          If your facility would like to improve regulatory compliance and quality of care, contact Avera Education & Staffing Solutions at (605) 668-8475.

           

          As a former health facilities senior surveyor, Marci worked at the Department of Health Office of Licensure and Certification for eight years. Marci provides Survey Preparedness Consulting designed to create a culture of constant survey preparedness by helping staff understand regulatory requirements, not just comply with them.

          Do the math! The facility bottom line improves when resident care continually improves.

          Read more Regulations Updates. The Avera Solutions’ Blog contains writings from Marci and other Avera Education & Staffing Solutions staff and consultants.

           


           

          Marci Pederson, RN, BSN

          Marci Pederson, RN, BSN

          As a former health facilities senior surveyor, Marci served a variety of health care facilities. Her experience includes nursing education, medical/surgical nursing, psychiatric nursing, infection control, utilization review and quality assurance.