documenting a chart check?

[ddrn97]

I just started a nursing job. I understand that each time we receive our patients, we check and overlook their charts which I always do with my preceptor. I was told that we enter a nursing order under our name for a "chart check" which then appears under the patient's orders. I never understood why we have to do it that way. Yesterday I forgot to enter the "chart check" orders for my patients, and I am unclear if this is an actual problem or not since I do not understand why we have to enter it. What do other hospitals and facilities do?

[psu_213, BSN, RN]

Is this "order" entered to indicate that you were in the chart and checked for orders? If so, it seems like a waste of time.

[ddrn97]

Yes that's exactly what I think the purpose of it is.

[chare]

I disagree that this practice is a waste of time, and doubt that your missing this is going to be a problem for you.

The chart check, which you are completing with your reviewing the orders at the start of your shift, is a long established practice. In addition to reviewing orders, the chart check should include reviewing lab or test results, the MAR, and if time permits notes. Back in the dark ages, when the patient's medical record was a stack if paper in a binder, after the nurse completed the chart check, he or she wrote a dated and timed entry on the first blank line on the orders page as an attestation the he or she had actually viewed the chart.

Best wishes.

[psu_213, BSN, RN]

I disagree that this practice is a waste of time, and doubt that your missing this is going to be a problem for you.

I guess I was going under the assumption (yes, I know, dirty word) that it was an electronic chart and this was a CYA thing. If it was an electronic chart, it is recorded that a particular nurse was in a chart, and just by adding "chart check," that does not mean a real chart check was actually done.

I haven't used a paper chart in quite a few years, but I would note "chart check" on the orders page, but I would not "enter" any sort of a order. I saw the point of enter the "chart check" note, but it still was kinda a waste of time.

[psu_213, BSN, RN]

Just wanted to add--with paper charts, orders were noted and signed off only if there were new orders. Night shift then did a 24 hour chart check, to make sure that all orders in the last day were taken off correctly (this was noted in the chart as well). Some people advocated a 12 hour chart check, so it was done on both days and night, however it was decided by someone that it was too busy on dayshift for a nurse to check off his/her 4 or 5 charts.

[KelRN215, BSN, RN]

Just wanted to add--with paper charts, orders were noted and signed off only if there were new orders. Night shift then did a 24 hour chart check, to make sure that all orders in the last day were taken off correctly (this was noted in the chart as well). Some people advocated a 12 hour chart check, so it was done on both days and night, however it was decided by someone that it was too busy on dayshift for a nurse to check off his/her 4 or 5 charts.

Yes, this. We did 24 hr checks to make sure all orders got transcribed onto the MAR or CarDex when I was doing my preceptorship and the hospital wasn't fully electronic. By the time I was a nurse on the same floor, all charting was electronic and 24 hr checks had gone away. There were many different ways the system would alert you if orders weren't signed off.

[LovingLife123]

Chart checks should be entered at the end of each shift so you can easily check the orders that were completed the previous shift and make sure none were missed. That's the actual purpose of them. It's actually very helpful.

Obviously if this patient is new to you, you review the whole chart. But say a last minute order is put in or someone just missed an order in a sea of new orders, a chart check helps cover that.

Sometimes, you have no new orders on a shift, and then you can quickly just complete it.

They are important and serve a purpose.

[JKL33]

It sounds like an extra step to document something, IMO. Less about whether the chart check itself is important or not.

It would be like having to enter an order for patient rounding so that you could document that you rounded.

You have number of more important things to worry about right now, but maybe after you're established a bit you could find out if this could be added to your facility's EMR build as a permanent area you can check off as "done." For now, it looks like their procedure is that you must enter the order to fire a task for you to complete.

[MunoRN, RN]

There is no reason to specifically document a "chart check" with an EMR, the purpose of a "chart check" with paper order entry was to make sure all the written orders had been transcribed, entered into the computer, etc, with current EMRs the order goes directly into the system. In some places it may have also been used to ensure that the nurse had reviewed recent orders, although that is now tracked automatically by the EMR.

Old habits are hard to break and sometimes in the switch to EMR we insist on continuing old habits even though they may no longer serve a purpose. "Signing off" orders for instance used to be how we checked the written order to how it was transcribed or entered into an EMR, I worked at a place that when they switched to no paper orders (computer order entry only) the act of "signing off" orders was so habitual that they were going to the orders screen and hitting "print screen" and then checking to make sure the printout of the orders screen matched the order screen.

[mrsboots87]

I work at both a hospital with an EMR and another one that is still paper. The paper hospital def needs a chart check. Any orders you follow are on you. If someone didn't transcribe the order correctly, you just made a med error or lab error or missed a treatment or what not. That's on you. By signing that's you've checked the chart, shows that you are accepting the chart and have corrected any errors if found. It also means you reviewed results of labs and radiology and such and are taking responsibility over calling docs, or greeting lytes or whatever. If you don't sign the chart, you are still liable for all this, but if an error does occur, it will look even worse for you.

[psu_213, BSN, RN]

It would be like having to enter an order for patient rounding so that you could document that you rounded.

A little off the topic, I worked on a unit that had a sign off sheet in each room that the nurse had to initial every hour to indicate that the nurse rounded. Most nurses just initialed it 12 times near the end of their shifts. It did help me to realize the silliness of pointless 'charting' (even though these sheets were not part of the medical record).