chart review

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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.

Can I get a copy of your form?

Thanks,

Pam

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Littlebit I am now in your shoes, looking for tools. Any help is appreciated. I have left emergency room nursing for now.

Thanks,

Pam

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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 do not know how to pm my email addy to you. Can you lead me?

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Specializes in Gerontology, Med surg, Home Health.

Sure...look at the little icons next to my screen name. Click on the one that looks like a piece of paper with a pen on it. Click on that....you should be able to send a PM. Or click on the envelope and you can send me an email.

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HI,,,,Just started as MDs/ADON......newbie here. I would gladly appreciate your guide for the chart review. Thanks a LOT:)

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Specializes in Gerontology, Med surg, Home Health.

I've posted the chart review below. It can be modified to fit your particular facility. I started with the things I knew were a problem to make sure I check those in every chart.

CHART REVIEW.doc

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Specializes in administration, med-surg, swing bed, inf.

may i get a copy of your chart review. love to see all your information, your poost have been very helpful to me

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Specializes in Gerontology, Med surg, Home Health.

Look up to the post before yours. The chart review is posted there.

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Thank you for posting your chart review!!! I will be starting as a new DON on Mon as this will be very helpful. I just love this site !!:bowingpur:loveya:

Tammy

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Specializes in administration, med-surg, swing bed, inf.

would love a copy of your chart reviw form

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Specializes in Gerontology, Med surg, Home Health.

Go to post #17 of this thread. The form is posted there.

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Specializes in administration, med-surg, swing bed, inf.

May I have a copy of the form also

Thanks in advance

4668

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