Who is responsible for maintaining resident clinical records in a facility?

The responsibility for maintaining resident clinical records in a facility primarily falls under the purview of the medical records department. This department is specifically tasked with ensuring that all clinical documentation is accurate, complete, and securely stored according to regulatory standards. Medical records professionals are trained to handle sensitive health information, ensuring confidentiality and compliance with legal and ethical guidelines.

While nursing staff, administrative staff, and social services play important roles in a resident's care and may interact with clinical records, they do not have the same level of responsibility for the overall management and integrity of those records. Nursing staff may contribute to documentation related to patient care, but the comprehensive maintenance, indexing, and retrieval of clinical records are duties designated to the medical records team, which possesses the necessary expertise and training for this specialized task.