What Are The Three Most Important Records In A Nursing Home?

There are three specific documents that are required on all nursing home charts under the federal law known as the Omnibus Budget Reconciliation Act (OBRA). If you are concerned about care provided to you or a loved one at a nursing home, you should ask to review the Minimum Data Set (MDS), the Resident Assessment Protocol (RAP), and the individual Care Plan with the medical director of the nursing home.

#1: Minimum Data Set (MDS): The Minimum Data Set is a comprehensive assessment of the resident’s functional capabilities and helps the nursing staff identify health problems. Certain items on the MDS will indicate that a resident is at risk, i.e. falling, pressure sores, urinary tract infections, etc. When a MDS shows a health problem, it triggers the Resident Assessment Protocol.

#2: Resident Assessment Protocol (RAP): After the Minimum Data Set is completed, a resident who has one or more risks (known as “triggers”) will trigger a Resident Assessment Protocol. This form is to provide clues as to risks presented by residents in nursing homes. The Resident Assessment Protocol is the foundation upon which a resident’s individual Care Plan is formed.

#3: Care Plans: The Care Plan should contain interventions to minimize injuries. Examples of such interventions include the use of a sitter and the use of bed and chair alarms for residents at risk of falling.