Paralegal resources · 8 min

Nursing home records checklist for attorneys and paralegals

The chart is only part of the record. This is the full list, organized by where it lives, with notes on what usually goes missing.

Start with the complete chart, defined precisely

A request for the medical record often produces a summary export rather than the working chart. Ask for the complete record from admission through discharge or death, in native or unredacted PDF form, including audit trails and late-entry flags where the facility uses an electronic health record. Name the modules: nursing, physician, therapy, dietary, social services, activities, and MDS.

• Face sheet, admission paperwork, and the arbitration agreement if one exists
• All MDS assessments, including the raw item sets rather than a summary
• Baseline care plan and every version of the comprehensive care plan with revision dates
• Nurse notes, physician progress notes, and consult reports
• ADL flow sheets, treatment administration records, and medication administration records
• Vital sign records with time stamps
• Therapy evaluations, progress notes, and discharge summaries
• Dietitian assessments, weight records, and meal and fluid intake documentation
• Wound assessments, measurements, and photographs
• Laboratory and imaging results
• Transfer forms, EMS run sheets, and hospital records for each transfer

Documents that are not in the chart

These are the records that decide cases, and they are usually held outside the clinical file by the administrator, the corporate office, or a third party.

• Incident and accident reports, and the facility's internal investigation file
• Daily staffing assignment sheets, the posted daily staffing notice, and time and attendance records
• Payroll-Based Journal submissions for the relevant quarters
• The facility assessment required at 42 CFR 483.71
• Facility policies and procedures in effect on the date of the event, not the current version
• Personnel files for staff involved, including background checks, training, and discipline
• Grievance logs, resident council minutes, and ombudsman correspondence
• QAPI and quality assurance committee materials, recognizing that many states protect these
• CMS Form 2567 survey results and plans of correction for at least three years
• Corporate ownership documents, management agreements, and budget or labor variance reports
• Video surveillance, plus the facility's retention policy
• Census and acuity reports for the dates at issue

What is usually missing from the first production

Expect to chase these specifically, by name, in a second request: wound photographs, the treatment administration record, repositioning or turning records, the facility assessment, the investigation file as distinct from the incident report, native MAR exports with time stamps, and the staffing assignment sheets for the specific shift.

Public records you can gather before discovery

CMS Care Compare publishes survey results, staffing data derived from Payroll-Based Journal submissions, quality measures, and ownership information for every certified facility. State survey agencies publish complaint investigation results in many states. For assisted living, the state licensing agency rather than CMS is the source, because assisted living is licensed by states and usually not certified by CMS.

What to send an expert first

For a screening call, an expert does not need the entire production. Send the admission assessment and care plan, the notes for the two weeks around the event, the incident report if you have it, the hospital records for the transfer, and the staffing sheets for that shift. That package supports a viability opinion in most cases.

This page is educational and is not legal advice. Regulatory citations reflect CMS State Operations Manual Appendix PP and 42 CFR Part 483; confirm the version in effect for your matter.