Chart Review

[NeuroNP]

How do you handle chart review on your unit? Is it done exclusively by nurses (or others) who do nothing else, or do staff nurses do it? If it's handled by staff nurses, is it done as part of your shift (ie, when you get down time? :rotfl: ) do you have to stay late/come in extra, or do you get so much time (ie, 1 shift a month/comp time) to do it? How do people resond to your method? What do you think would be a better way?

I personally have worked in a setting where nurses did all the chart review and had to come in on days off (paid of course) to do it or try to squeeze it between other duties, and in a setting where other nurses (not clinical staff nurses) did it. I feel that staff nurses should be involved in it because that allows them to see mistakes made and then possibly "educate" them to things to watch out for in their own charting. However, people didn't like the idea of having to come in "extra" to do them. Maybe having one shift a month "off the floor" to do nothing but chart review is a good idea?

bryan

[meownsmile, BSN, RN]

Our nurse administration and utilization review department usually do them. The only time we hear about a chart is if we have something we need to finish or sign off on.

[plumrn, BSN, RN]

We use to have to do them, but we are way to busy to get them done now. There is no way I'm coming in on a day off to do them. I don't really know who does them now. If we had a shift set aside for paperwork once a month, I wouldn't mind that. It would be helpful, and a nice break from the routine.

[Tweety, BSN, RN]

It used to be done by the clinical nurse educator, now it's being done by all profressionals. We have one to do a month and have to fill out a form that names the name of the person who was deficient in any areas. Then we turn that in to the charge nurses who use it as an "educational tool" to improve our charts.

When I worked another unit as a charge nurse I did them all for the unit because as the night shift charge they figured I had the most time, and the day charges did other things.

I hate chart reviews, but see their value. Keeps us on our toes. I'm not sure I like the peer-review thing, we've only done it a couple of months now.