"Nursing Chart Review Template"

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CHART REVIEW - NURSING
Months Reviewed:
Date:
Reviewer:
Patient Name:
Agency:
Branch:
1. Circle all services provided:
SN
ST
OT
PT
Aide
MSW
2. Start of Care:
Discharge:
NURSING CRITERIA
ORDERS
A. Plan of Care
Please circle
3. The initial Plan of Care is signed by physician within 60 days of SOC.
Yes
No
N/A
4. Subsequent Plans of Treatment are signed by physician and dated within 30 days.
Yes
No
N/A
5. All pertinent diagnoses are included in the plan of care.
Yes
No
N/A
6.Goals are measurable and realistic?.
Yes
No
N/A
7.Plans of treatment are filled out completely .
Yes
No
N/A
8. Parameters for vital signs, blood sugars, etc. to be reported to doctor are included.
Yes
No
N/A
9.PT, OT, ST, MSW ordered when indicated
Yes
No
N/A
B. Telephone/Verbal Orders
11. All changes covered with written orders.
Yes
No
N/A
12. Orders are written for new or changed medications or documented doctor to patient.
Yes
No
N/A
13. Verbal orders 60 days.
PROGRESS NOTES
14. SN Visit frequency consistent with POT/verbal orders.
Yes
No
N/A
15. Documentation to explain all missed visits. Physician notified?
Yes
No
N/A
16. All orders on POT are performed as evidenced on progress note for that certification period.
Yes
No
N/A
17. SN goals are evidenced/documented on each progress note.
Yes
No
N/A
18. Care coordination is documented.
Yes
No
N/A
19. Appropriate and timely intervention in response to needs.
Yes
No
N/A
20. Measurable progress/deterioration noted.
Yes
No
N/A
21. Notes signed, dated, completed by SN. Filing according to policy.
Yes
No
N/A
MEDICATIONS
22. Medication sheet is completed?
Yes
No
N/A
23. Medication sheet is updated as changes are made.
Yes
No
N/A
C
R
- P
2
HART
EVIEW
AGE
CHART REVIEW - NURSING
Months Reviewed:
Date:
Reviewer:
Patient Name:
Agency:
Branch:
1. Circle all services provided:
SN
ST
OT
PT
Aide
MSW
2. Start of Care:
Discharge:
NURSING CRITERIA
ORDERS
A. Plan of Care
Please circle
3. The initial Plan of Care is signed by physician within 60 days of SOC.
Yes
No
N/A
4. Subsequent Plans of Treatment are signed by physician and dated within 30 days.
Yes
No
N/A
5. All pertinent diagnoses are included in the plan of care.
Yes
No
N/A
6.Goals are measurable and realistic?.
Yes
No
N/A
7.Plans of treatment are filled out completely .
Yes
No
N/A
8. Parameters for vital signs, blood sugars, etc. to be reported to doctor are included.
Yes
No
N/A
9.PT, OT, ST, MSW ordered when indicated
Yes
No
N/A
B. Telephone/Verbal Orders
11. All changes covered with written orders.
Yes
No
N/A
12. Orders are written for new or changed medications or documented doctor to patient.
Yes
No
N/A
13. Verbal orders 60 days.
PROGRESS NOTES
14. SN Visit frequency consistent with POT/verbal orders.
Yes
No
N/A
15. Documentation to explain all missed visits. Physician notified?
Yes
No
N/A
16. All orders on POT are performed as evidenced on progress note for that certification period.
Yes
No
N/A
17. SN goals are evidenced/documented on each progress note.
Yes
No
N/A
18. Care coordination is documented.
Yes
No
N/A
19. Appropriate and timely intervention in response to needs.
Yes
No
N/A
20. Measurable progress/deterioration noted.
Yes
No
N/A
21. Notes signed, dated, completed by SN. Filing according to policy.
Yes
No
N/A
MEDICATIONS
22. Medication sheet is completed?
Yes
No
N/A
23. Medication sheet is updated as changes are made.
Yes
No
N/A
C
R
- P
2
HART
EVIEW
AGE
P
N
:
M
R
#:
ATIENT
AME
EDICAL
ECORD
ASSESSMENT / REASSESSMENT (OASIS)
24. Assessment completed within timeframe per policy/regulation
Yes
No
N/A
25. Reassessment completed according to policy/regulation
Yes
No
N/A
ADMIT INFORMATION
26.
All admission paperwork is completed and signed?
Yes
No
N/A
27.
If Advance Directive is completed, copy in the chart? Documentation present?
Yes
No
N/A
HOME HEALTH AIDE
28. Specific documentation on assessment on admit or recert to justify need for HHA.
Yes
No
N/A
29. HHA frequency is consistent with Plan of Care and verbal orders.
Yes
No
N/A
30. Documentation to explain all missed visits with physician notification.
Yes
No
N/A
31. Any problems reported by HHA are followed up by case manager or clinical supervisor.
Yes
No
N/A
32. The HHA care plan is developed/revised based on the patient’s needs according to the
Yes
No
N/A
plan of care or as patient changes warrant.
33. HHA supervisory visit according to plan of care or policy.
Yes
No
N/A
34. The HHA follows the care plan and documents performance of assigned tasks.
Yes
No
N/A
35. The HHA reports problems to appropriate personnel.
Yes
No
N/A
36. Vital sign parameters are on care plan when aide is assigned to take vital signs.
Yes
No
N/A
37. Notes complete and signed. Filing according to policy.
Yes
No
N/A
DISCHARGE
The physician is notified of discharge.
Yes
No
N/A
38.
A discharge summary is complete
Yes
No
N/A
39.
40. 5 day notice to physician and patient.
Yes
No
N/A
(
Additional comments on the back)
HCL / Chart Review - Nursing
Rvd. 051306
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