24hr Chart Checks

Are the checks being done, and orders are still being missed? Maybe the nurses don't really know how to do it.

Thanks for the reply PricklyPear,

As far as i know the nurses are doing 24hr chart checks or just signing that they did, but really have not checked to see if all medications or diagnostic testing have been ordered.....

I need to formulate something that shows that all medications/diagnostic testing have been ordered and verified by the nurse in order to avoid missing orders.

CosmoLVN

Thanks for the reply PricklyPear,

As far as i know the nurses are doing 24hr chart checks or just signing that they did, but really have not checked to see if all medications or diagnostic testing have been ordered.....

I need to formulate something that shows that all medications/diagnostic testing have been ordered and verified by the nurse in order to avoid missing orders.

CosmoLVN

I wish you luck on coming up with something like that. I used to work at a hospital where each order was given a number by the computer. The clerk (or whoever entered it) would write this number next to the order in red ink. That way, when we did our 24h checks, we could see at a glance that the order had been entered. I always thought that was a great system. As far as meds, I have no idea how you could check up on that. I work nights, and I have always considered it my personal responsibility to do 24h checks - ESPECIALLY on meds. Other nurses don't. I hate to say it, but if errors are found that should have been caught by the 24h check nurse, the only recourse might be an incident report on that nurse, as well as the nurse who took it off. They usually make people stand up and take notice!

Hello everyone,

I need some help. I have been asked to work with my nurse manager to work on a special project.

I currently work nights on a Med/Surg unit and latley there her been some issues on missed orders. My project is how we can improve 8hr/12hr/24hr nursing chart checks in order to avoid missing orders? Please let me know if you have any suggestions......Thank You !

CosmoLVN

First, I'd ask all of your night staff what the problem is. Tell them of a couple of really scary misses with the focus of the teaching being that night shift is the day's LAST CHANCE to get it right for the patient. Ask them for ideas on improvement.

Maybe they need to get to a computer and there aren't that many available. Maybe they trust the other staffers a little too much and they're not checking some people's as carefully as another's. Maybe they're unfamiliar with the correct order as it appears in the computer. We used to have a problem with people ordering CRPs instead of what the docs wanted, a Highly Sensitive CRP.

Or maybe there's a communication breakdown. For instance, doc orders a back brace but the communication is lost because the nurses earlier couldn't reach the company that supplies the equipment. We use a communication book for noting that so it'll be followed up. We also have a lab continuation book for orders like "daily PT/INR." Nothing fancy, just a plain old notebook that's kept at the desk.

Generally, I print up the orders for the past 24 hours and do most of my chart checks before I assess each patient unless there are pages and pages of orders. Reason is, some docs come in very late and fail to give the order to the unit secretary, and if there are missed orders, I'd jolly well better find them so I don't have to call the doc at 0300.

I compare my printout with the chart's written orders and put the number of the order in red pen in a discreet margin. Then I leave the printout in the front cover of the chart so if there are any questions, it can be looked at.

If something's missed, I call the desk and ask the US to verify that it is indeed missing, and if it is, to please input it. I then make a note to recheck it.

This is what keeps us night shifters humble, and why we really would like the other shift nurses to walk a mile in our shoes---EVERYONE MAKES MISTAKES. EVERYONE HAS MISSED ORDERS OR MIS-TRANSCRIBED ORDERS. Some of our best nurses are no better than some of our worst in this area. You have no idea how many times I've been late with my meds or my patient care because I was scrambling all night to fix a huge mistake that was made sometime early that day. OK. Off the soap box and on to the method.

If I can't read it, it goes up to the desk for what we fondly call "The Translation Game." Anyone can play. They take a look at the order and try to read the doc's handwriting. This takes us a few minutes but because we usually succeed, it saves the day shifters that call to clarify an order that says some mundane thing like "Pls shave patient qd" or "...if OK w/ pt's primary" except that instead of writing "primary" out, he wrote a 1 with a degree sign. :rolleyes:

To be honest, IF YOU HAVE TIME, when you get a transfer from another unit, look over ALL the orders. You wouldn't believe the stuff we've caught.

Mostly, it's a matter of convincing the night nurses that the 24-hour chart checks can literally mean the patient's life if a significant order is missed or mis-transcribed.

Sorry this was so long.

I highly suggest a chart check at the end of each shift, with the oncoming nurse. This way it is a double check with two nurses, as well.

I have taken that into consideration......my only concern would be how time consuming would that be? I know that probably that should not be a big deal when it comes to patient safety, but as we all know that change of shift never seems to be a very smooth transition

Will what ever I come up with. I have to present this to the staff at a staff metting and get some input on the ideas I have come with. Thank you for the suggestion. If you come with any other helpful tips please let me know....

CosmoLVN

A q shift chart check does not take that long and should be done by the off going nurse. Everywhere I have ever worked has required this be done. I also agree that order # or a confirmation sheet should be placed in the chart for verification by the RN. In the long run this cuts down on overlooked orders, gives the RN a reference to back up her signing off orders, and is just good practice. It may take a little time to get everyone on board, and some will gripe, but in the end it is worth the extra effort.

Is there any reason the offgoing nurse on that shift, initial the bottom of the page of orders after they are checked. We sign off on the order slip when we pull it from the chart to verify time and who did it. But at the end of 8 hour shifts each Rn could go back through her patients charts and initial the bottom of the page verifying that it has been checked and orders are complete. That would also make it her responsibility if something is still missed and it was initialed. I wouldnt think it would take that much time, not any more than the time it takes for all the banter and chit chat at shift change anyway. Its only 5-8 patients maybe right?

What meow says is true. Once you date, time and initial the shifts orders YOU are stating your are responsible and have verified the orders are completed to the best of your ability. It has saved me time and time again when another department lost an order. I could give them date, time, order # of procedure. Saved a physician from yelling at me, he yelled at them instead. Chart checks are just another safety measure held over from the old days of nursing that have proven to be very good measure to continue today.

Our hospital requires us to "Red Line" each chart at the end of each shift. We of course sign our orders off as they are written. We must verify that each of the orders has been entered into the computer. Our MAR is computerized, so as you are checking them on the computer you are comparing them with the chart at the same time. At the end of your shift, a red line under the last set of orders written, along with your name, credential, date and time shows that you have checked all of the orders and have verified that they are entered into the computer or on the kardex correctly. This system seems to work pretty well at our hospital. Hope this helps.

We did something similar to this too. At shift change the coming and leaving nurses would look over the orders written during the previous shift to be sure they were taken off and then we would write with RED ink the date and time and the nurse leaving would sign her name and then the coming nurse would sign hers beside it after a slash. For example:

11/11/11 Chart Check

1900 Jane Doe, RN/Betty Boop, RN

It was pretty neat because you knew the orders were taken off, PLUS you could look and see that if there were several "chart checks" written one after another without orders between them, that there had not been orders written on the patient for that many shifts. We worked in an intensive care nursery where the patients often stayed for a long time and didn't always need orders written each day. We all worked 12-hour shifts too.

I loved chart checks because it made you be sure you had reviewed the chart at the beginning of your shift and didn't find out something late in the shift that you should have known hours earlier! There is not much worse in my book! It also was nice to have the chart there and open so I could quickly look at the most recent progress note, etc.

Yes, I miss chart checks at my new place of employment..... Sigh