chart review

Specialties LTC Directors

Published

I am new in my position as DON. We should be having a survey in the next 2-3 months and I am trying to prioritize what I should be reviewing. Does anyone have a checklist on what I should be reviewing in the residents charts? The facility I am at has had "poor survey results" in the past and documentation was a problem. Or does anyone know of a website that can help guide me and let me know where I should I start.

Thanks for any guidance.

Up Vote Up Vote ×
Specializes in Gerontology, Med surg, Home Health.

Start at the beginning of the chart and work your way through.

1.Are all the consents signed?

2.Is there a health care proxy? Is it invoked and did the 'right' person sign the consents? Around here, HCP has been a huge issue. Some places are getting cited because the HCP was NOT invoked but the HCP signed the consents.

3. Are there 15 months of MDS in the chart?

4.Nurses' notes there? Is there anything in the notes which would make your hair stand on end? I read one a while ago which said "Resident impacted...disimpacted..." Duh....the resident was constipated and got a suppository...totally different scenario.

5.Are the care plans up to date?

6.Are the MD orders signed and current?

7. Is there a diagnosis for every medication?

8. Has there been a GDR attempted for any psychotropic?

I made myself a chart review form. I'd be glad to send you a copy.

Pay special attention to the sections the facility got tagged on during the last survey and make sure you concentrate on those areas first.

Up Vote Up Vote ×

Capecod

I would really appreciate your form. I have some serious work to do and again like I said I am not sure where to start.

Thanks

Up Vote Up Vote ×
Specializes in LTC/SNF.
Start at the beginning of the chart and work your way through.

1.Are all the consents signed?

2.Is there a health care proxy? Is it invoked and did the 'right' person sign the consents? Around here, HCP has been a huge issue. Some places are getting cited because the HCP was NOT invoked but the HCP signed the consents.

3. Are there 15 months of MDS in the chart?

4.Nurses' notes there? Is there anything in the notes which would make your hair stand on end? I read one a while ago which said "Resident impacted...disimpacted..." Duh....the resident was constipated and got a suppository...totally different scenario.

5.Are the care plans up to date?

6.Are the MD orders signed and current?

7. Is there a diagnosis for every medication?

8. Has there been a GDR attempted for any psychotropic?

I made myself a chart review form. I'd be glad to send you a copy.

Pay special attention to the sections the facility got tagged on during the last survey and make sure you concentrate on those areas first.

I am currently in my survey and would greatly appreciate if you could send me a copy of your form also, i know it is not going to help now but will with plan of correction.:bowingpur

Up Vote Up Vote ×

CPR status updated or in the chart.

PASSAR in the chart

DX list

Doc orders signed

Lab work done as ordered....or even just done.

Assessments done quarterly or sooner (dietary, SS, etc)

Wounds are measured and tracked

No wholes on the MAR, TAR CNA sheets.

Up Vote Up Vote ×

Capecod

Please PM me

Thanks so much

You will be able to use the PM and Email function on this board when you have 15 posts on the board.You may receive PM's but you cannot send until you have made 15 posts.Please do not post your Email address on the public board as this is against the TOS of the site,which you agreed to when you signed up.

Nightmare.....Moderator.

Up Vote Up Vote ×
Specializes in acute care and geriatric.

I would suggest you make a list of what needs to be checked from a to z then hold a meeting with your head nurses and give them a check list...You might have to ask for overtime to get this done right esp if you ( the facility) got poor results in the past.I can not stress enough housekeeping and havin the CNA's clean up the rooms etc - (if 2 pts share a room, their hygienic supplies like toothbrushes should not be together...)

Care Plans were a big thing and I took that on myself as my nurses were not strong there.

BTW CCM mentions reading the chart for hair raising stuff- I would ask your head nurses to go over that etc.

Weight changes are a big thing as well,

The list is endless- you cant be everywhere so enlist your headnurses and have them assign their staff to help them-

Good Luck!!!

Up Vote Up Vote ×
Specializes in LTC, ER, ICU, Psych, Med-surg...etc....

Go thru the chart...start at the beginning. Look at the MDS information. Is the MDS accurate? Check physicians orders. Are you following the orders? If you have orders for geri sleeves, are they on? If you have orders for tube feeding are you running at the correct rate? Do you have labs ordered? Are they done? Results on the chart? Physician aware? RP aware? What other orders do you have? Are you following them? Medications? Are you documenting on the MAR that they are administered? Are they being administered correctly? Are you crushing what you shouldn't or giving with meals what you should? If you have psych meds...are dose reductions done/recommended and physician responded? Behaviors monitored? Side effects monitored? Is the diet appropriate? If need assistive devices, are they being used? Are splints on and documented? Is restorative nursing done and documented? Are showers and BMS documented? Is your resident interviewable? Have you spoken to them about what their life is like and if they have any concerns regarding their care? Look at the Nursing notes...has anyone written anything that is a red flag, like fecal impaction, or digital removal of stool, or found in floor because alarm was off...or crazy stuff? Speaking of falls...are the ordered devices on and functioning- at all times. And is all this on your care plan? Is it updated when there are any changes? Pressure sores...look at those....was it unavoiadable? Could you tell someone else how it is unavoiadable? Update careplan???? Family or RP always aware/notified of changes? MD sees resident per schedule? If you say you're doing something for a resident, are you really doing it, or just writing it on paper? OBSERVATIONS are an integral part of the survey process as well as going through a chart. There is plenty more, but I'll stop now....

Up Vote Up Vote ×
Specializes in LTC, ER, ICU, Psych, Med-surg...etc....

One thing about holes...it can be a two-fold problem...either it was done and not documented, or not done at all. So no holes!

Up Vote Up Vote ×
Specializes in Geriatrics.

I would also like to have a copy of your form. Thanks for sharing

Up Vote Up Vote ×
Specializes in ortho,med-surg,neuro,CQI\LTC,homehealth,.

Good room rounds always sets the tone for a survey. Make sure that the residents room is neat,clean and clutter free. Make sure callbells are in reach.Over head lights are clutter free. No community personal care items,make sure all personal care items are labeled and or bagged. Urinals,basins etc should be bagged and labeled in residents bathroom.O2 concentraters set correctly,O2tubing dated,filters cleaned, and H20 bottle/cannister with appropriate amt in it. Feeding pumps cleaned,with enteral feeding bottle/bag dated and labeled.Refrigerater clean,thermometer in place and temp log posted. I hope this helps also.

Up Vote Up Vote ×

CapeCod I Could use your form, as I am a new DON. Thank You so much. I enjoy reading your posts. I learn alot from this site.

Thanks,

Pam

Up Vote Up Vote ×
+ Add a Comment