07/09/2026

Survey Tip of the Week: Complete Medical Records

The Medical Records F-tag 842 is one of the top ten most frequently cited F-tag in Ohio for calendar year 2026. A common issue leading to citations is the absence of information in residents' medical records regarding the delivery of care and services. The State Operations Manual requires facilities to maintain medical records that are:

• Complete
• Accurately documented
• Readily accessible
• Systematically organized

Recent survey citations demonstrate that facilities are frequently cited for documentation failures involving:

• Change in condition assessments that were never documented.
• Missing nursing progress notes surrounding hospital transfers or resident deaths.
• Treatments, wound care, catheter care, or compression stockings documented as completed when they were not.
• Medication Administration Records (MARs) or Treatment Administration Records (TARs) signed before care was actually provided.
• Missing ADL, meal intake, bowel movement, skin assessment, or intake documentation.
• Failure to document physician notifications, family notifications, or follow-up after significant events.
• Documentation that conflicted with observations made by surveyors or other medical records.
• Missing documentation supporting wound progression, nutrition monitoring, or acute clinical changes.

The Long-Term Care Survey Process instructs surveyors to evaluate if the medical record provides sufficient information for staff to respond to the changing status and needs of the resident.