CHART/PATIENT MEDICAL RECORD:

A 12-hour chart check will be performed prior to the end of the shift on all inpatients and observation wherever they are housed.  All orders and documentation for the previous 12 hours will be reviewed in both the electronic and hard back chart by the Registered Nurse. 

The following is the process to follow in conducting the chart check:

1.       Review all orders and documentation for the previous 12 hours

How to acknowledge orders

Check orders column

Red and Green flags mean routine and stat orders. Double click on flag, lists all orders since last check and any orders not acknowledged the last time the flag was viewed. You can select all orders or some of them and view details of the order if necessary.

Right click on any order from the orders tab and choose history to see who acknowledged the order and what time it was acknowledged

2.        Review the chart for HELD and Suspended orders

Use the filters on the right side of the Orders tab. All HELD and suspended orders will have the icon. Ensure the status of these orders has been communicated

3.        Review and complete orders no longer relevant

4.        Review all Active orders

5. Licensed care providers may delete duplicates, using yourself as the source, in the following categories:

• Diet
• Activity
• Vital signs
• Primary maintenance IV fluids

6. Determine all patient care orders scheduled to be executed in the last 12 hours have been implemented or communicated to ancillary departments.

If any orders for evaluation or treatment could not be executed, the nurse caring for the patient enters an explanatory note in the Patient Record.

7.     Verify completion of all relevant data:

• Patient profile  
• Biophysical assessment data
• Braden assessment 
• Restraint observations
• Meds, IV's and blood products
• IV volumes in I & O
• Drain outputs on I & O flowsheet
• Vital signs
• Intake and Output
• Meals/snacks/percentages
• ADL's
• Unit approved waived lab tests
• Lab orders: ordered, collected, statused in EMR/cancel specimens not collected or 
  cancel order in EMR
• Falls screening

 8.   Complete the 12 hour chart check “order” for your shift and enter a chart check order for the next shift to complete

ELECTRONIC DOWNTIME PROCEDURE:

A 12-hour chart check is performed on all charts on inpatient and observation patients wherever they are housed.

1. Collect proper documents.

• Patient's hard copy record including 24-hour flowsheets, lab slips, x-ray and procedure 
  requisitions, MAR

2. Verify the following parameters:

• All new medical orders received during the last 12 hours are found in hard copy on 
  the chart.
• All patient care orders scheduled to be executed in the last 12 hours have been carried 
  out or communicated to ancillary departments.
• If any orders for evaluation or treatment could not be executed, the nurse caring for 
  the patient enters an explanatory note in the Patient Record.

3. Verify completion of all relevant data.

• Patient Profile  
• Biophysical assessment data
• Braden assessment
• Restraint observations
• Med, IV's and blood products:  documented in patient record
• IV volumes in I & O
• Drain outputs on I & O flowsheet
• Vital signs
• Intake & Output
• Meals/snacks/percentages
• ADL's
• Unit tests: Guaiac, Blood Glucose
• Meals/snacks/percentages
• Falls screening

4. Verify lab collections/results

• Unit tests: Guaiac, Blood Glucose

5. Communicate follow-up instructions at report and document in nurses' notes.
6. Document 12-hour chart check completed on hard copy with signature, title, 
   date, time on hard copy.

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