Hey guys, my hospital just recently went from the paper charts to CPOE. We used to compare our paper chart orders with the computer at night to make sure we had a good 24 hour chart check. Well now we have no paper, JUST the computer. How do your night shift RN's do a 24 hour chart check now? We're trying to get each unit to do the same thing really, any insight would be appreciated. The old chart check method kind of sucked because we had a lot of info in the computers(charting, progress notes, labs, etc, etc), AND had the paper chart..so some physicians would put info in the paper chart, some in the computer chart, sort of hybrid.

The purpose of 24 hour chart checks was to make sure the orders in the paper chart were all entered into the computer and entered correctly based on how they were written. With CPOE the are entered directly into the computer so there's no need to make sure they made it from the chart into the computer and there's no risk of misreading a Physicians order since they order it themselves.

The only thing that needs to be checked is the appropriateness of orders of you have a CPOE system that works.

We have a function on our EHR that states chart review. We use this to look at the orders that were put in during the day to make sure what has been discontinued is really discontinued and if theres any order left to carry out that wasnt done on day shift (we are paperless also)

To touch on what Muno said...even though the MD puts in their own orders, we've had instances where stat labs are ordered, consults are ordered, blood, etc..but day shift just clicks review or signs it off(without actually making sure it's been done). Other problems we seem to be having are rate changed on TPN, different fluids being ordered, but no one ever addressing it correctly. When you come in at night, there's no flag that you have orders that need to be completed. I'm thinking we need to reinforce to day shift the importance of making sure what you sign off, really is done. We also have problems of orders being put in right at shift change(1846, 1859 even). When the night shift comes in and you set up your PAL list from 7p-7a. You have no flag of an order that was put in at 1859. I'm gonna try to get with IS about that one too. But really I'm seeing some accountability issues with the previous shift not truly looking at it.

Use your Patient Access List. It should have everything there for a quick review.

We review all active orders together at shift handoff.

I'm thinking we need to reinforce to day shift the importance of making sure what you sign off, really is done.

THIS!

There is no 24 hour chart review with CPOE.