Do assisted living facilities keep medical records?

Oct 20, 2025 4 min read •

senior care assisted living Health Information

By law, assisted living facilities must maintain records for each resident, which includes critical health information, and implement secure procedures for their use. Understanding how facilities manage these confidential records, and whether assisted living facilities keep medical records, is crucial for ensuring proper care and legal compliance.

Quick Summary

Yes, assisted living facilities are legally required to keep and manage resident records, including pertinent medical and health information, in a secure and confidential manner. Facilities follow specific protocols to document health status, medications, and care plans, ensuring continuity of care while respecting privacy laws like HIPAA, depending on their level of service.

Key Points

Legally Required Record-Keeping: Assisted living facilities must maintain comprehensive, confidential records for every resident, documenting identifying information, health history, and care plans.
Ensuring Continuity of Care: Accurate and up-to-date records are crucial for providing consistent care across staff shifts, preventing errors, and ensuring timely, appropriate interventions during emergencies.
Compliance with Privacy Regulations: While not all facilities are full HIPAA "covered entities," many follow its privacy and security standards as a best practice, especially if they handle electronic protected health information.
Transition to Electronic Records: The adoption of Electronic Health Records (EHR) is increasing, improving accessibility, efficiency, and accuracy compared to traditional paper-based systems.
Coordination with External Providers: Facilities communicate and collaborate with outside healthcare professionals, such as doctors and specialists, to manage residents' health needs effectively, always with proper consent.
Security is a Priority: Facilities must implement secure storage procedures for both physical and digital records to prevent unauthorized access, loss, or disclosure, and ensure data integrity.

The Core Role of Record-Keeping in Assisted Living

Record-keeping in assisted living is not merely an administrative task; it is a foundational element of providing personalized, effective, and safe care. Meticulous documentation, whether paper-based or electronic, allows staff to have immediate access to a resident's critical information, which can be life-saving during emergencies. These records serve as a comprehensive communication tool, ensuring all staff members are aligned with a resident’s care plan and that consistency is maintained across shifts and departments.

What Information Is Kept in Resident Records?

The contents of a resident's record are comprehensive and include more than just medical history.

Identifying Information: Name, date of birth, address, and contact information for the resident and their legal representatives.
Emergency Contacts: The names, addresses, and phone numbers of the resident's emergency contacts.
Health Information: A detailed medical history, allergies, diagnoses, and any treatments or therapies that require documentation.
Medication Records: Comprehensive records of all medications administered, including dosage and frequency.
Advance Directives: Any advance directives, such as a living will or a "do not resuscitate" (DNR) order.
Care Plans: The facility's current and previous assessments and individualized service plans.
Progress Notes: Documentation of significant changes in the resident's status and the actions taken in response.
Incident Reports: Records of any incidents involving the resident and the actions taken.

Legal and Ethical Obligations of Assisted Living Facilities

Assisted living facilities are bound by a complex web of legal and ethical requirements regarding resident records. The most prominent of these is HIPAA, the Health Insurance Portability and Accountability Act. While not all assisted living facilities are automatically considered "covered entities" under HIPAA, many choose to follow its guidelines as a best practice for privacy and security. Facilities that electronically transmit Protected Health Information (PHI) for billing or work as a business associate with a covered entity, such as a hospital, are required to comply with HIPAA.

Facilities must establish written procedures for the use, storage, and security of resident records. This includes controlling access to records and establishing criteria for the release of information. Disclosure of personal, financial, or medical information is only permitted under specific conditions, such as with the resident’s written authorization or when required by law.

The Shift to Electronic Health Records (EHR)

Many assisted living communities are moving away from traditional paper-based record-keeping toward Electronic Health Records (EHR) systems. This transition offers numerous benefits for both the facility and its residents.

Accessibility: EHRs provide quick and easy access to a resident's complete health history, enabling timely and informed decisions, especially in emergencies.
Efficiency: Digital records streamline administrative tasks, reduce paperwork, and improve the overall efficiency of record management.
Accuracy: EHR systems minimize the risk of data entry errors, ensuring the accuracy and completeness of medical information.
Integration: EHRs can integrate with other software, facilitating seamless information exchange with external healthcare providers, like physicians and specialists.

How Facilities Coordinate with Outside Healthcare Providers

Resident care often requires collaboration with external healthcare providers. Assisted living facilities facilitate this coordination through clear communication and robust record-sharing protocols.

Care Plan Sharing: Facilities share relevant portions of a resident's care plan and health history with their primary care physicians and specialists, with proper consent.
Scheduling and Transportation: Staff often assist with scheduling and arranging transportation for residents to off-site medical appointments.
On-Site Visits: Many facilities have arrangements with local doctors who make regular, scheduled visits to the community to assess residents.
Partnerships: Facilities may partner with home health agencies, hospice providers, and physical therapy services to deliver specialized care on-site.

Comparison: Assisted Living vs. Skilled Nursing Records

The record-keeping processes in assisted living and skilled nursing facilities, while both crucial, differ due to the fundamental differences in the level of care provided.


Feature	Assisted Living (AL)	Skilled Nursing Facility (SNF)
Environment	More residential, focuses on social engagement and help with daily activities.	More clinical, focuses on round-the-clock medical care and rehabilitation.
Medical Intensity	Manages stable medical conditions; licensed nurses are often on-site part-time.	Provides intensive, 24/7 medical care with licensed nurses on-site.
Record Depth	Records focus on assessments, service plans, medication administration, and significant changes.	Records are more extensive, detailing multiple diagnoses, daily nurse assessments, and intense therapy regimens.
HIPAA Applicability	Not always a "covered entity," but often follows HIPAA as best practice or when transmitting PHI.	Almost always a "covered entity" under HIPAA due to the high level of medical care and billing activities.
Documentation Detail	Documentation primarily reflects assistance with activities of daily living (ADLs) and monitoring overall wellness.	Documentation includes frequent licensed nurse notes and detailed records of medical treatments and therapies.

Conclusion: The Importance of Secure and Accessible Records

In conclusion, assisted living facilities are required to keep detailed and secure medical records for residents. This practice is essential for providing continuous and high-quality care, particularly in emergencies. Through organized record-keeping, often utilizing modern EHR systems, facilities ensure all staff have access to the information needed to support residents' health and well-being. Furthermore, strict adherence to privacy protocols, whether mandated by HIPAA or adopted as a best practice, builds trust and protects residents' sensitive information. For families, this robust system of record management provides peace of mind, knowing their loved one's health is carefully and professionally tracked.

Visit the Department of Health and Human Services for more information on HIPAA laws

Frequently Asked Questions

Assisted living facilities collect a variety of medical information, including the resident's medical history, allergies, current diagnoses, medication lists, and details on any required treatments or therapies. This is all documented in a confidential resident record to guide their care.

The application of HIPAA can vary. Assisted living facilities are not automatically considered "covered entities" under HIPAA unless they electronically transmit protected health information for billing or act as a business associate for a covered entity. However, most facilities adopt HIPAA's privacy and security standards as a best practice.

Access to your medical records is strictly controlled and limited to authorized facility employees and contractors who need the information to provide services. Disclosure to other parties, including family members, requires your written consent, unless otherwise mandated by law.

Yes, you have the right to request and receive a copy of your medical records. The facility may charge a reasonable fee for copying the records, but they cannot deny your request.

When a resident is discharged or moves, the assisted living facility is required to retain their record for a specified period, often five years or more, as per state or federal regulations. A summary of the resident's record is also typically conveyed to the new care provider with consent.

The retention period for resident records varies by state, but it is typically a minimum of five to ten years after the resident's discharge or termination of services, or as otherwise required by law.

Facilities are required to implement security measures for both physical and electronic records. This includes using locked cabinets or rooms for paper files and robust cybersecurity measures, like encryption and access controls, for digital records to prevent unauthorized access or disclosure.

References

Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.