Nursing Home & Long-Term Care Records
What should I know about nursing home & long-term care records: access guide?
Learn how to request nursing home and long-term care facility records. Covers resident rights, care plans, incident reports, and accessing records for loved ones.
Federal law gives nursing home residents stronger records rights than most people realize—and faster timelines than standard HIPAA. If a facility is stalling, they're likely violating the law. Here's what you're entitled to and how to get it.
Resident Rights to Records
Federal Nursing Home Reform Act guarantees nursing home residents the right to access their complete clinical records within 24 hours of request (workdays), and receive copies within 2 working days.
Right to Access
Residents have the right to examine their complete clinical record, including all assessments, care plans, physician orders, and nursing notes.
Right to Copies
Facilities must provide copies within 2 working days. They may charge a reasonable, cost-based fee for copies but cannot deny access based on cost.
Right to Request Amendments
Residents can request corrections to inaccurate information in their records. The facility must respond within 30 days.
Right to Designate Representatives
Residents can authorize family members or others to access their records on their behalf through written authorization.
What Records Nursing Homes Keep
Every nursing home is required by federal law to keep detailed records. Here's what exists and what you can request:
MDS Assessment
Minimum Data Set - full resident assessment
Frequency: Quarterly and upon significant change
Includes:
Care Plan
Individualized plan developed with resident/family
Frequency: Initial, then updated quarterly
Includes:
Physician Orders
Medical orders from attending physician
Frequency: Ongoing, reviewed monthly
Includes:
Nursing Notes
Daily documentation by nursing staff
Frequency: Daily/per shift
Includes:
Medication Administration Records
Documentation of all medications given
Frequency: Every dose
Includes:
Therapy Records
Physical, occupational, speech therapy notes
Frequency: Each session
Includes:
Additional Records That May Be Available:
- • Incident/accident reports
- • Fall risk assessments
- • Skin integrity assessments (wound care)
- • Weight and nutritional monitoring
- • Social service notes
- • Activity participation records
- • Advance directives and DNR orders
How to Request Nursing Home Records
1Submit Written Request
Put it in writing. Address your request to the medical records department or administrator and include:
- •Resident's full legal name
- •Date of birth
- •Dates of residency (admission to present or discharge)
- •Specific records requested (or "complete clinical record")
- •Delivery preference (mail, electronic, pick up)
2Include Authorization (If Applicable)
If you're requesting on behalf of a resident, the facility needs to see your authority. Bring the right document:
- •Healthcare Power of Attorney: Copy of the POA document
- •Legal Guardian: Court order appointing guardianship
- •Written Authorization: Signed by competent resident
- •Deceased Resident: Death certificate + executor documentation
3Know the Timeframes
These are federal minimums—not suggestions. If the facility misses them, that's a violation:
- •Review records: Within 24 hours of request (workdays)
- •Receive copies: Within 2 working days
- •Facilities cannot charge for review time
- •Copying fees must be reasonable and cost-based
If the Facility Delays or Denies
- 1.Put your request in writing with a specific date
- 2.Cite federal regulations (42 CFR 483.10(g))
- 3.Contact the state Long-Term Care Ombudsman
- 4.File a complaint with your state health department
Family Member Access
When the Resident Is Competent
A competent adult resident controls who sees their records. That includes family members—even adult children. Written authorization is required:
- •Must provide written authorization naming you
- •Can specify which records you may access
- •Can revoke authorization at any time
- •Authorization should be kept in the resident's file
When the Resident Has Dementia or Is Incapacitated
When a resident can no longer make decisions, the legal representative steps in. The hierarchy matters:
- •Healthcare Power of Attorney: Must have been signed while competent
- •Court-Appointed Guardian: Full guardianship or specific medical authority
- •State Default Laws: Some states have hierarchy for next-of-kin decisions
If no legal representative exists, you may need to petition the court for guardianship.
After the Resident Passes Away
Death doesn't eliminate the right to records. The estate's representative can access them:
- •Executor or administrator of the estate
- •Personal representative (with court documentation)
- •Provide death certificate and proof of representative status
Special Situations
Incident/Accident Reports
Incident reports are where facilities push back hardest. Know how to request them correctly:
- •Incident reports in the clinical record are accessible
- •Some facilities claim reports are "quality assurance" and protected
- •Request the report as part of complete clinical records
- •For litigation, subpoena may be needed for additional documents
Records for Legal Cases
Records are your foundation before any legal action. Get them early, before evidence disappears:
- •Request complete records before filing any lawsuit
- •Document request dates and responses
- •Consider consulting an elder law or nursing home abuse attorney
- •Preserve original records - don't alter or annotate
See our guide: Medical Records for Lawsuits
Transferring to Another Facility
Don't trust the facility-to-facility transfer alone. Get your own copies:
- •Request records be sent to the new facility
- •Get your own copy for continuity
- •Include discharge summary and current care plan
- •Current medication list is essential
Facility Closure
A closure doesn't make records disappear. They have to go somewhere:
- •Records must be transferred to a successor or archive company
- •Contact your state health department for record location
- •State Long-Term Care Ombudsman can help locate records
Frequently Asked Questions
How do I get medical records from a nursing home?
Submit a written request to the medical records department or administrator. Include the resident's full name, date of birth, dates of stay, and what you want. If you're a family member, attach your authorization document—power of attorney, healthcare proxy, or court order. Without it, the facility can legally refuse.
Can family members access nursing home records?
Not automatically. Family members need either written authorization from the resident, healthcare power of attorney, or a court order. Being a spouse or adult child is not enough on its own. For deceased residents, the executor or personal representative can request records with proof of that status.
What records does a nursing home have to keep?
Federal law requires nursing homes to keep MDS assessments, care plans, physician orders, medication records, nursing notes, therapy records, lab results, incident reports, and discharge summaries. Records must be kept for at least 5 years—longer in many states.
How do I get incident reports from a nursing home?
Request them as part of your complete clinical records. Facilities will sometimes claim they're “quality assurance” documents and refuse—that's often wrong. Incident reports in the clinical record belong to the resident. If the facility keeps refusing, cite 42 CFR 483.10(g) and contact the state ombudsman. Subpoenas are a last resort for litigation-only documents.
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