Chart Audit

[Breathing16]

How often do RN's get their charting audited? Is it only during evaluation times (yearly) and sentinel events? Or is it more of a regular occurrence at your facility?

Also, what types of items are the main concerns? What should be my top charting priorities?

Thank you, AN.

[HyzenthlayLPN]

That would depend on your facility :)

At my facility (where I assist both Infection Control and Quality Assurance) I audit charts daily, though I am looking for specific things, NOT to see how a specific nurse is doing on her charting. Unless one of the things I am specifically looking for is consistently missing, the nurse will never know the chart was audited.

An example of what I might look for: catheters and central lines. Each day I pull a list of every patient with a catheter or central line and I look for charting that tells me when (when was the catheter (or PICC) put in or when was port-a-cath accessed? By whom? Was there an order? Is the catheter justified (i.e. Why does this patient have a catheter?)) You would NOT believe how often the charting doesn't answer these basic questions...

We have a case manager that reviews charts daily for utilization. Does this patient NEED to be in a hospital (according to their insurance)? I don't do this audit (but performed a similar function in my last job) and I would love to see charting from the nurse that reflects WHY this patient is in a hospital and NEEDS in-patient care. Seriously, if the nurse (at least as reflected in her charting) spends less 15 minutes of a 12 hour shift with a patient and barely completes a check-the-box assessment...why would an insurer pay for in-patient care??

The best rule for charting was one we all learned in nursing school "If it isn't charted, it didn't happen!" You are a nurse...tell management (and the insurance company) WHY the patients need you and all you do for them...you work hard...make sure you tell them about it!!

Also, if there is ever an issue with a patient (such as a lawsuit) keep in mind you might very well have to answer questions about this patient (what their dxs were, what you did for them and why you did it) 3 to 5 years from now! Chart now in a way that your future self will know how to answer those questions :)

[rn2015tonow]

At my facility, chart audits happen daily, but it is usually not to see how a specific nurse is charting. That usually only occurs around review time. Otherwise it is for infection control, quality, prevalence studies, etc.