Which records should I upload for a nursing home case?
For a nursing home case, upload the full facility chart, the hospital records and the ambulance run sheets. The facility chart matters most: the MDS assessments, the care plan, the medication and treatment records, and the aide flowsheets. Medrecords AI reads what you upload and cites each page. It does not fetch records for you.
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The facility chart
These are the records most cases turn on. The table explains each term in plain words.
| Record | What it is |
|---|---|
| Admission packet | Forms signed at move-in. It can hold the BIMS score (a short memory test) and any arbitration agreement |
| MDS | The Minimum Data Set. A long resident assessment done at admission and on a set schedule after |
| Care plan | What staff promised to do, such as turning every 2 hours or weekly weights |
| MAR | Medication administration record. Each dose given, held or refused |
| TAR | Treatment administration record. Wound care, creams and other treatments |
| CNA flowsheets | Aide records of turning, meals, fluids, toileting and bathing. Also called ADL records |
| Nurse notes | Shift notes and notes on any change in condition |
| Skin and wound records | Skin checks, wound measurements and Braden scores (a scale for bed sore risk) |
| Weight and intake records | Weights, meal percentages and fluid intake |
| Fall records | Fall risk scores, post-fall notes and alarm or bed-check logs |
| Physician orders and progress notes | Orders, order changes and doctor visits |
| Dietitian and therapy notes | Diet changes, supplements and therapy progress |
Records from outside the facility
- Hospital records. Every hospital stay. The emergency room note often gives the first outside view of a wound, a fracture or weight loss.
- Ambulance run sheets. They show the resident's state when they left the facility.
- Wound clinic or outside doctor records, if any.
- Death certificate and autopsy, in a death case. See our guide on nursing home wrongful death records.
Inspection reports and staffing data
Medrecords AI does not pull state inspection reports or PBJ staffing data (the payroll-based staffing reports nursing homes send in). If you have a CMS-2567 inspection report as a PDF, you can upload it. It is read like any other PDF. The app does not treat it in a special way. Our guide to the MDS and the CMS-2567 explains what those forms hold.
How to upload
- Upload PDFs, images, Word files or text files. ZIP files unpack in your browser.
- Save TIFF, GIF or HEIC files as PDF or JPG first. The app does not read them.
- Upload the whole chart, even if it repeats. Duplicate pages are removed for you. See how duplicate pages are handled.
See which files you can upload for the full list.
Handwritten flowsheets
Many aide flowsheets are filled in by hand, with check marks and initials. Handwriting and faint scans are where reading mistakes are most likely. Open the source page for any flowsheet entry you plan to rely on. See check any fact against its source page.
Records that come in later
Production often comes in pieces. You can add records to a case at any time. See add records to an existing case. Then check what is still missing. See check whether the MDS, care plans and flowsheets are there.
Medrecords AI organizes and cites the records. Its output is not a medical or legal opinion and does not replace your expert.
Related help
- Review a nursing home neglect case
- Set up a nursing home case
- Which files can you upload?
- Read our guide on records for a nursing home fall case.
Facts checked against the Medrecords AI app code on 2026-10-24.