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The kind of chart review I am thinking of is where one aspect of the computerized care plan would be checked to see how many nurses are utilizing it ( documenting it).
E.G.; daily wts or teaching or assessing and documenting respiratory status.
This would be too lengthy in terms of time to be covered in a monthly meeting as usually 3-4 criteria are selected from the care plan each month.
Anyone observed anyone doing this? Someone must be checking to see that the nurses are documenting on EVERYTHING !
Thanks for your input trrauma nurse...
It might be possible in a real small unit.
I need more input and info. This could be a NEW job for some of us with the change to laptops.
98 looks and one reply...
is anyone doing chart reviews?? Does the lack of replies mean No one knows?
Can you all ask around?? Find out ?? This would be a great job for nurses who are sick & tired of bedside nursing....
I beginning to think computerized charting is as prevalent as some think it is.
At the hospital that I am preceptoring at (and have done all of my clinical time), the nurses are supposed to review and update all of the computerized charting for each of their clients on each shift. There isn't always time on dayshift, but those on nightshift do it, so it is done once every 24 hours. Our hospital is not large enough to justify hiring someone to do it exclusively and really, I think it is appropriate for the nurse assigned to those clients to do it. The nurse who has just spent 12 hours with that client will know if an action is no longer necessary or if new actions are. Just my relatively inexperienced opinion.
Chart auditing can be the task of any number of titles, depending on the institution's job descriptions. You might be looking for performance improvement, quality, utilization, or case management jobs. Those are the ones that pop into mind as "chart auditors".. Seems like regardless of whether the documentation is computerized or not, someone has to audit for compliance, JCAHO standards and plain old utilization.
We have a committee that meets and does this at intervals. It falls under the risk management departmentm, who oversees it. On the individual units the charge nurses and managers also do some QA and occasionally some random chart checks...and assign them to the nurses too. Usually it falls on night shift to do.
passing thru
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Just curious and wondering if there are new 8-5 jobs opening for nurses to do "chart reviews."
I'm sure this is still being done - but haven't come across any nurses visiting our unit and doing the reviews.