Who does the chart reviews at your hospital?? Now that you are "computer charting?"

Trauma Columnist · Feb 4, 2004

I work level one trauma center. Our chart reviews are done by each other at our monthly shared governance meeting. Sorry.

passing thru · Feb 4, 2004

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.

passing thru · Feb 5, 2004

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.

RN auditor · Feb 5, 2004

I do chart reviews almost exclusively in my position. We do not have electronic charts yet but if we did I would be the one responsible for auditing them for compliance. My position is RN Auditor. I think there could be need for a FT chart auditor in many hospitals.

LydiaGreen · Feb 5, 2004

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.

catlover314 · Apr 6, 2004

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.

mattsmom81 · Apr 6, 2004

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.

Shellsie · Apr 7, 2004

when we went live on the computerized charting we put into place a "PCM coodinator" who does chart audits daily along with teaching class, updates, etc.