CHART Reviews

Penelope_Pitstop, BSN, RN · May 22, 2008

i would perform my chart checks as soon as possible, even though i wouldn't sign that i did them until after midnight. i would start from the last twenty four hour chart check, so if there hadn't ever been one, i'd do the entire chart! i'd start with the newest set of orders and work my way back, making sure the mars and the computer "current orders" were indeed current, and that all orders had been carried out as needed. after i did my initial chart check, i'd wait until after the 2400 med pass, do my flowsheets, then go back to my charts and make sure i missed no orders, then sign the chart indicating i'd checked it. after this, i'd check labs, read h & p's, consults and progress notes.

on the other hand, whenever i worked day or evening shifts (rarely!) i did my checks no earlier than an hour before my shift ended.

jess

imanedrn · May 22, 2008

We do chart checks at change of shift always. Is is an essential part of report. The off-going nurse reviews the orders from her shift with the on-coming nurse. If anything is left undone, there should be a good reason (i.e., too late for MRI) or the chart technically shouldn't be signed.

Just yesterday, though, I found out that there was a med error made and several nurses (including myself) were involved. Apparently, on Tuesday, a PO narcotic had been d/c'd. It was a T.O. written by the day nurse. If she were doing her job properly, she should have checked the E-MAR during HER shift to ensure the med was removed. If not, she should have re-faxed the order to / phoned pharmacy to ensure it was removed. Then, along with the night nurse, they should have confirmed this together while doing their chart check. When I came on Weds AM shift, I did my chart check with the night nurse. She point blank told me the patient was receiving this PO narcotic for break-through pain. (He was on a dilaudid PCA.) With that being said, I can only imagine she did not properly review the orders (d/c the PO narcotic, specifically) from the previous (day) shift, but I'm not going to assume...

In any case... it is NOT expected that each shift reviews the orders from TWO shifts ago. We are only expected to review those from the PREVIOUS shift. Otherwise, I'm sure you could imagine chart checks / report taking forever. There are some nurses who will skim through (some more detailed than others...) previous orders, but (again) this is not required.

Nightcrawler, BSN, RN · May 23, 2008

We don't co/sign the chart at report- although we should, but I make sure that I look at orders over the last 12 hours prior to entering the room for the first time to make sure that I have a clear picture of what is going on.

Just after midnight I sit down to do a formal chart check- make sure that all labs and tests were ordered correctly, that nothing was missed etc.

The one difference that I am seeing between my floor and what the rest of you are talking about is that we compare the MAR to all of the orders written since admission or transfer to the floor. Say that the patient came up from the ICU 5 days ago- then I would look at all med orders for the past 5 days. For those patients that have been with us forever and a day, I will do a chart check from the last time that I checked the chart. So if I took care of the patient two weeks ago I would check the chart for only the last two weeks, and not for the three months that they have been with us.

That of course was an extreme example, most of our patients are not with us for that long, but the point is that we check ALL of our med orders and reconcile them every night to make sure that a narc that was dc'd two days ago doesn't stay on the MAR. Mistakes still happen, but they don't happen as much as they could. I can say that chart checks take much longer on the first night than the second or third, because then you are only checking for one days orders

husker_rn, RN · May 23, 2008

When I was in the hospital setting I never got to my chart checks until after midnight; however I always pulled my charts right after report to make sure orders had been noted.....often found things that were missed so took care of those immediately then checked thoroughly later.

Daytonite, BSN, RN · May 23, 2008

what does your hospital policy have to say about this? first of all, i would incorporate what ever your hospital policy wants done into your practice. i always made a quick check of doctor's orders to see that they have at least been signed off at the beginning of the shift to make sure that no orders have been left unnoticed. this only takes a few minutes. i did more complete checking (i made sure the doctor's orders were properly transcribed and carried out; i often read progress notes very quickly) throughout the shift as per our policy by priority. i had a way of marking my report sheet so that i kept track of which charts i had completed. the sicker and more active patient's charts got monitored first because there had been more activity in them. before i clocked out i made sure that i had checked every single chart or i didn't leave. some places that i worked did not have the staff rns doing chart checks. the unit secretaries or charge nurses did it. the person's who put their signature on those orders they sign off have to take the brunt of the responsibility if they weren't processed correctly. however, mistakes happen. if they do, focus first on looking for them where they are going to do the most damage or are likely to occur--the sickest and more unstable patient(s) or where new orders are flying left and right.

Drysolong · May 24, 2008

what does your hospital policy have to say about this? first of all, i would incorporate what ever your hospital policy wants done into your practice. i always made a quick check of doctor's orders to see that they have at least been signed off at the beginning of the shift to make sure that no orders have been left unnoticed. this only takes a few minutes. i did more complete checking (i made sure the doctor's orders were properly transcribed and carried out; i often read progress notes very quickly) throughout the shift as per our policy by priority. i had a way of marking my report sheet so that i kept track of which charts i had completed. the sicker and more active patient's charts got monitored first because there had been more activity in them. before i clocked out i made sure that i had checked every single chart or i didn't leave. some places that i worked did not have the staff rns doing chart checks. the unit secretaries or charge nurses did it. the person's who put their signature on those orders they sign off have to take the brunt of the responsibility if they weren't processed correctly. however, mistakes happen. if they do, focus first on looking for them where they are going to do the most damage or are likely to occur--the sickest and more unstable patient(s) or where new orders are flying left and right.

thanks for all of your responses. what prompted my question was that i worked in icu one night and happened to read their guidelines, which in part stated that chart reviews should be done at the beginning of the shift. that made sense to me. in my unit (medsurg) i was following the example of previous preceptors and fellow co-workers- and as i stated, whenever i could. now, i am trying to implement better organization at work.

Virgo_RN, BSN, RN · May 25, 2008

I give the charts a quick once-over at the beginning of my shift, but save the thorough chart checks for when I have time. The beginning of my shift is typically very busy, and I usually have to dive right in and don't have time to sit down and note off orders. If we have a resource nurse available, I'll ask him or her to do my chart checks, or if another nurse is caught up, they'll make the offer.

RedhairedNurse, BSN, RN · May 25, 2008

I'm a new nurse and have a question about chart checks. Sometimes the charts are very thick, so what I want to know is.....When doing chart checks do you just scan and make sure all orders have been signed off on? Or do you read each individual order and compare with the MAR? It just seems like this would take so much time. Please let me know the correct way of doing a chart check. Thank you

Daytonite, BSN, RN · May 25, 2008

what prompted my question was that i worked in icu one night and happened to read their guidelines, which in part stated that chart reviews should be done at the beginning of the shift.

i recall being floated to icu in one facility where i worked where this was done. a copy of all the doctor's order sheets were kept in a manila file for each patient. this is how they dealt with not being able to get their hands on the actual chart all the time. the nurses gave face to face report with the oncoming nurses with these manila folders and doctor's order sheets which they reviewed during report. that kind of goes along with what i said earlier that the sicker patients and those with orders flying left and right get looked at first. what better example of this than patients in an intensive care unit?

imanedrn · May 27, 2008

We don't co/sign the chart at report- although we should, but I make sure that I look at orders over the last 12 hours prior to entering the room for the first time to make sure that I have a clear picture of what is going on.
Just after midnight I sit down to do a formal chart check- make sure that all labs and tests were ordered correctly, that nothing was missed etc.
The one difference that I am seeing between my floor and what the rest of you are talking about is that we compare the MAR to all of the orders written since admission or transfer to the floor. Say that the patient came up from the ICU 5 days ago- then I would look at all med orders for the past 5 days. For those patients that have been with us forever and a day, I will do a chart check from the last time that I checked the chart. So if I took care of the patient two weeks ago I would check the chart for only the last two weeks, and not for the three months that they have been with us.
That of course was an extreme example, most of our patients are not with us for that long, but the point is that we check ALL of our med orders and reconcile them every night to make sure that a narc that was dc'd two days ago doesn't stay on the MAR. Mistakes still happen, but they don't happen as much as they could. I can say that chart checks take much longer on the first night than the second or third, because then you are only checking for one days orders

This is precisely what happened in my example. It seems so exhaustive to review PAGES of orders (some illegible!) just to make sure a med was NOT missed :banghead: