Medical Records Request Checklist
For Nursing Home Litigation — Lexcura Summit Medical‑Legal Consulting
Our Approach
This checklist ensures you obtain all the records necessary to evaluate, organize, and litigate a nursing home case with accuracy and speed. Use it during intake, discovery, and expert preparation.
I. FACILITY RECORDS (NURSING HOME)
A. Admission & Administrative Records
Admission agreement
Consent forms
Arbitration agreements
Power of attorney / guardianship documents
Face sheet / demographic sheet
Insurance information
Physician orders (all)
Transfer forms
B. Care Planning & Assessments
Comprehensive care plans (all disciplines)
Quarterly and significant‑change care plans
MDS assessments (all versions)
RAI/MDS supporting documentation
Interdisciplinary team notes
Baseline care plan
C. Nursing Documentation
Nursing notes (RN/LPN)
CNA flow sheets
ADL documentation
Vital signs logs
Intake/output records
Change‑in‑condition notes
Pain assessments
Skin assessments
Fall assessments
Behavior monitoring sheets
D. Medication & Treatment Records
Medication Administration Records (MARs)
Treatment Administration Records (TARs)
Pharmacy delivery logs
Controlled substance logs
PRN usage documentation
Medication error reports
E. Therapy Records
PT/OT/ST evaluations
Daily therapy notes
Therapy care plans
Discharge summaries
F. Wound Care Documentation
Wound assessments
Wound care flow sheets
Wound measurements
Photos (if taken)
Wound consult notes
G. Nutrition & Hydration
Dietary assessments
Weight logs
Meal intake records
Hydration logs
Dietitian notes
H. Incident & Investigation Records
Incident reports
Witness statements
Internal investigations
Root cause analyses
Facility response plans
I. Facility Policies & Procedures
Pressure injury prevention
Fall prevention
Infection control
Change‑in‑condition
Staffing policies
Documentation standards
Emergency response
II. HOSPITAL & EMERGENCY DEPARTMENT RECORDS
A. Emergency Department
Triage notes
ED provider notes
Imaging reports
Labs
Nursing notes
Medication administration
B. Hospital Admission
Admission H&P
Progress notes
Consult notes (wound care, infectious disease, ortho, etc.)
Operative reports
Imaging
Labs
Discharge summary
C. Ancillary Providers
Wound care centers
Dialysis centers
Hospice
Home health
Pharmacy records
III. PHYSICIAN & PROVIDER RECORDS
Attending physician notes
NP/PA notes
On‑call physician communications
Orders (all)
Progress notes
Consultations
IV. REGULATORY & ADMINISTRATIVE RECORDS
Staffing schedules
Assignment sheets
Timecards
Agency staffing logs
Training records
Facility census logs
State survey reports
Complaint investigations
Plan of correction
V. HIGH‑VALUE RECORDS OFTEN MISSED
These are the records that frequently reveal systemic failures:
Call light response logs
Bed alarm logs
Transfer sheets
Therapy refusal logs
Behavior monitoring sheets
Pain management logs
Physician notification logs
SBAR communication forms
24‑hour reports
Shift change reports
VI. RED FLAG DOCUMENTATION TO REQUEST IMMEDIATELY
These items often indicate deeper negligence:
Unexplained bruising documentation
Late entries
Retrospective charting
“Copy‑and‑paste” patterns
Missing assessments
Contradictory entries
Gaps in documentation
Incident reports that don’t match the medical record
Need help evaluating your case?
Lexcura Summit provides fast, accurate, litigation‑ready medical‑legal analysis for nursing home cases nationwide. If you want clarity on records, deviations, or causation, we’re here to support your strategy.