breaking down charts

ttouslee · Nov 13, 2013

We do computer charting, but its amazing how much paperwork is still in the office charts. When we breakdown the chart, all Dr. orders, including referrals, F2F, signed 485's, are kept. Pretty much anything with someones signature is kept. H & P along with demographic sheet are also kept. These are all put into a manilla envelope with client name and dates of service written on the outside. Then stored in the office for 1 year. after that it goes to outside storage for 10 years (longer than required) This is probably all over kill as everything with signature has been scanned into computer chart, but I am old school and can not force myself to have a paper with dr. signature on it being shredded! Hope this helps some

Tampa121 · Nov 20, 2013

I, also perform medical record reviews on discharged ptrveys (me-the only nurse) yep-saga continues. Sorry! But, now Administrator tells me to perform MR Audits on our dc pts. It is my understanding these are performed Quarterly-6 page audit tool via Select Data .com. I was hired 8/12/13 and admitted our first pt 8/29/13.Am I responsible to perform the Audits on pts. In Jan. 2013 an RN who resigned admitted a few pts Jan. 2013 for Mock survey, prior to my hire date. Am I responsible to perform Audits that an RN who resigned admitted a few pt' s for a mock survey? I beleive I am not. Thank you, Kathy ps:Any advice or websites you can email me will be greatly appreciated. Thank you All Nurses!

KelRN215, BSN, RN · Nov 21, 2013

We don't store paper charts in the office. Everything is saved in an online cloud. Even our fax is electronic so we don't get a hard copy of any 485s with MD's signatures.