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]

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.

I only was there for a 'go live' once for an electronic chart--we were switching from 99% paper to 99% electronic. Naturally, some nurses did not like the idea of a change. Some veteran nurses insisted on still have a hand written Cardex for each patient. So for each new patient, the nurse had to create a paper Cardex even though the EMR would generate one that you could see with 2 clicks. Much like the Cardex, documenting a "chart check" seems like it is another relic that has survived the switch from paper to electronic charts.

[Alex_RN, BSN]

Are you on paper charts? That was the last time I had to document chart checks. We would page through recent orders and it was not unusual to find something that a previous nurse missed, sometimes a few days ago. or longer. Maybe "reviewed paper chart" is a line I should add in my EMR nursing note.

[Have Nurse, ADN, RN]

Never heard of that before. I don't know anyone who does that the way that you describe. Sounds like some personal preference by someone else up the chain.

[Wuzzie]

Never heard of that before. I don't know anyone who does that the way that you describe. Sounds like some personal preference by someone else up the chain.

I've never heard of it either. Not in three decades of nursing.

[K9lover, ASN, RN]

I remember back in the dark ages!

[hawaiicarl, BSN, RN]

Oh please please please don't let anyone in admin at our hospital read this, "someone" will think this is an awesome idea!

Cheers

[walkingrock, ADN]

No chart checks since paper orders. However, in the EMR we "time mark" recent labs and notes, and are flagged if there are new orders, new lab results, late meds, etc; so we can take care of them.