Chart Reviews

  1. We are a small Critical Access Hospital and are doing 100% chart audits. The ER and outpatient charts are reviewed the day after seen in the hospital. Many times the doctors orders are not written at the time of the chart audit. They gave the nurse's verbal orders while in ER and then never got around to actually writing them down on the chart. Are they allowed to chart after the patients have been discharged, currently the practice at this hospital is to flag what they need to order and give them back the chart. They get the charts back in a couple of days with the correct orders. To me it seems like after the fact charting that shouldn't be allowed, but not sure how to fix the problem.
    I am a new Utilization Review officer....they didn't even have the position before I was hired, so I am learning all I can by GOOGLE searches Thanks for your help
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    About Allie911

    Joined: May '10; Posts: 33; Likes: 13
    School Nurse; from ID
    Specialty: 5 year(s) of experience in Pediatrics