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Nursing Home Chart Audit
Care plan, MDS, falls, nutrition and staffing documentation, organized for attorneys and legal nurse consultants working nursing-home neglect cases.
Paste the nursing-home records you have: care plans, MDS excerpts, nursing notes, incident and accident reports, weight logs, dietary and dietitian notes, physician orders and progress notes (up to 50,000 characters). The audit organizes what the chart literally says: a resident snapshot, the care-plan problems and interventions with the gaps between them and the events in the notes, every fall with whether a post-fall assessment and care-plan revision appear, every documented weight charted with percent change computed on this page from the documented values, nutrition and hydration interventions, medications a reviewer would look at, staffing and supervision language, incident reports, whether the physician was notified after each reportable event, a dated timeline, flags and the records to request next. It does not diagnose, does not state what staff should have done, and nothing is invented: every date, weight and dose is pulled from your text with a quote.
The record was long and the analysis stopped before the end. Run the later dates as a separate excerpt.
Summary
Resident snapshot
Care plan
Falls
Weights
Nutrition and hydration
Medications of concern
Staffing, supervision and incident reports
Physician notification
Flags
Timeline
Gaps in the record
How to use the result
- Read the care plan against the events. A fall, weight loss, new wound or behavior that appears in the notes but never appears as a care-plan problem, or a care plan whose last review date precedes the events, is the documentation gap most surveyors and experts start with. The gap list states absences in the pasted text; confirm them against the complete care plan with every revision.
- Falls table: look at the two badges. "Post-fall assessment" and "Care plan updated after" are read only from your excerpt. "Unknown" means the excerpt is silent, not that nothing was done. Request the incident report, the 24-hour report and the care-plan revision for each fall date before relying on a "no".
- Weight chart: the percentages are arithmetic, not findings. This page computes change from the first documented weight and, when dates parse, over 30, 90 and 180-day windows, using the 5% / 7.5% / 10% thresholds facilities commonly use in their own weight policies. Weights in a nursing-home chart are often wrong (different scales, clothing, re-weighs). Treat a flag as a reason to request the complete weight log and the dietitian's assessment, not as proof of loss.
- Medications of concern are review prompts. The tool lists only drugs in your text and ties each to something else in the text (a fall, sedation, a missing diagnosis). Whether any order was appropriate is a question for a pharmacist or physician expert and for the MAR and pharmacy consultant reviews.
- Physician notification: "no" needs a quote. A "no" is set only when the record affirmatively shows no notification. Pair each "unknown" with a request for the full nursing note and the facility's change-in-condition policy.
- Verify every quote against the page it came from before it goes into a chronology, demand letter or expert packet.
What to request next
- Complete MDS assessments (admission, quarterly, annual, significant change) and the CAA worksheets
- Comprehensive care plan and every revision, with dates and signatures
- 24-hour report / shift report for the dates of each fall, weight entry and change in condition
- Staffing sheets, assignment sheets and PBJ (Payroll-Based Journal) data for the shifts in the window
- Incident and accident reports, fall investigations and root-cause reviews
- Physician orders, progress notes and the telephone-order log; pharmacy consultant reviews
- Dietary and dietitian notes, weight logs, meal-intake and fluid-intake records, supplement orders
- MAR and TAR for the window; PRN administration records with documented indication and response
- State survey results (Form CMS-2567), plans of correction and complaint investigations for the facility
- Facility policies on falls, weights and nutrition, change-in-condition notification and staffing
Need this across the whole chart?
MedLegal AI's Records Analyzer and Timeline Builder read the complete nursing-home record (thousands of pages), pin every finding to a Bates page and build the chronology for the demand or expert packet. Free account to start.