chart breakdown

Specialties Med-Surg

Published

I have been working on med-surg floor about two weeks now and was asked to break down patient chart. What does that mean and how do you do it?

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Have you asked someone that you worked with? They should be more than happy to help you out on that :)

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Specializes in Trauma Surgical ICU.

Ask someone on your unit, what is or isn't kept in the chart after DC or death is facility specific.

What it means is the pt is DC'd or died and the chart needs to be broken down and sent to billing/coding or to medical records..

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Specializes in Emergency, Telemetry, Transplant.

The specifics vary from hospital to hospital, unit to unit. When I worked on units that used paper charts: take all of the paper out of the chart (lab reports, physician orders, progress notes, nurses notes, etc.) and then got rubber banded and sent to medical records. The plastic chart dividers (that divided that chart into the sections previously listed) were pulled out and put back into the now empty chart (i.e. the physical binder--not full of women :geek:) and the chart was ready to be used for a new pt.

As someone else said, ask a coworker for the exact procedure on your unit.

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Okay thanks

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