Administrative Code

Creating a Report: Check the sections you'd like to appear in the report, then use the "Create Report" button at the bottom of the page to generate your report. Once the report is generated you'll then have the option to download it as a pdf, print or email the report.

Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 371. Regulations for the Licensure of Nursing Facilities

12VAC5-371-360. Clinical records.

A. The nursing facility shall maintain an organized clinical record system in accordance with recognized professional practices. Written policies and procedures shall be established specifying content and completion of clinical records.

B. Clinical records shall be confidential. Only authorized personnel shall have access as specified in §§ 8.01-413 and 32.1-127.1:03 of the Code of Virginia.

C. Records shall be safeguarded against destruction, fire, loss, or unauthorized use.

D. Overall supervisory responsibility for assuring that clinical records are maintained, completed and preserved shall be assigned to an employee of the nursing facility. The individual shall have work experience or training that is consistent with the nature and complexity of the record system and be capable of effectively carrying out the functions of the job.

E. An accurate and complete clinical record shall be maintained for each resident and shall include:

1. Resident identification;

2. Designation of attending physician;

3. Admitting information, including resident medical history, physical examination, and diagnosis;

4. Physician orders, including all medications, treatments, diets, restorative, and special medical procedures required;

5. Progress notes written at the time of each visit;

6. Documented evidence of assessment of resident's needs, establishment of an appropriate treatment plan, and interdisciplinary plan of care;

7. Nurse's notes written in chronological order and signed by the individual making the entry;

8. All symptoms and other indications of illness or injury, including date, time, and action taken on each shift;

9. Medication and treatment record, including all medications, treatments and special procedures performed;

10. Copies of radiology, laboratory and other consultant reports; and

11. Discharge summary.

F. Verbal orders shall be immediately documented in the clinical record by the individual authorized to accept the orders, and shall be countersigned.

G. Clinical records of discharged residents shall be completed within 30 days of discharge.

H. Clinical records shall be kept for a minimum of five years after discharge or death, unless otherwise specified by state or federal law.

I. Permanent information kept on each resident shall include:

1. Name;

2. Social security number;

3. Date of birth;

4. Date of admission and discharge; and

5. Name and address of legal representative, if any.

J. Clinical records shall be available to residents and legal representatives, if they wish to see them.

K. When a nursing facility closes, the owners shall make provisions for the safekeeping and confidentiality of all clinical records.

Statutory Authority

§§ 32.1-12 and 32.1-127 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 17, eff. July 1, 1997; amended, Virginia Register Volume 22, Issue 7, eff. January 11, 2006; Volume 37, Issue 17, eff. May 27, 2021.

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.