UT-Harris County Psychiatric Center

Nursing Procedures

 

Chart Checks

 

Date of Last Review:  4/07

 

Chart checks are completed to ensure that all orders have been entered/transcribed and executed. This check prevents omission of a treatment, medication or documentation.

 

Procedure:

 

1. Licensed staff is responsible for completing a chart check on each shift (8hr/12hr); the third shift will complete a 24 (twenty-four) hour chart check.
2.

The 8-Hour chart check includes but is not limited to:
 
  • Checking to ensure that all orders have been accurately transcribed/entered and executed
 
  • Checking to ensure that medication consents are signed/entered
 

The 24- Hour chart check includes but is not limited to:
 
  • Nursing Assessment Completion
 
  • DIR
 
  • Weights
 
  • Vital Signs Entries
 
  • Patient Rights Signature Form signed or revised every 24 hours
 
  • Advanced Directive Form
 
  • Orders executed for 2h hour time frame
 
  • Consents
 
  • Laboratory results
 
  • Allergies
 
  • MTP Problem entered by Physician
 
  • MTP Review every 7 days
 
  • MTP Signatures of disciplines per discussion with patient
 
  • Legal form chart for involuntary patient /LRE/1ST machine

Nurses are encouraged to check charts at anytime during the shift. The nurse is required to check each patients chart to assure that:

1. All orders are transcribed/entered accurately
2. All ordered treatments are entered onto the MAR and entered into the patient’s electronic medical record (Sunrise Clinical Manager).
3. All test referrals and procedures are transcribed/entered into the electronic medical record (Sunrise Clinical Manager).
4. All consents are signed. - Medical Consents, Patient Rights signature sheet.
5. Nursing documentation is reflected as appropriate.
6. All 1:1’s/precautions/observations must be reordered every 24 hours. The initial order is entered into Sunrise Clinical Manager.
7. All handwritten medication orders are pulled and sent to the pharmacy. Computer generated medication orders do not need to be pulled and sent to pharmacy---the pharmacy receives their own copy at the time of ordering.
8. All orders will be verified through an electronic chart check in Sunrise Clinical Manager.
  • As the nurse logs on to Sunrise Clinical Manager, he/ she will check the column marked “Check Orders”. If there is a green flag in that column beside a patient’s name, the nurse will double click on that flag, review the orders.
  • If the orders are correct, the nurse will select the button at the bottom of the window that says “Clear Flag”.
  • If the orders are not correct, the nurse will select the button at the bottom of the window that says “Don’t Clear Flag”. The nurse will then contact the doctor (if necessary) and make any corrections to the orders that are appropriate.
  • If there is no green flag in the “Check Orders” column beside the patient’s name, that indicates that there are no new orders to verify (or check) and the nurse can move on to the next patient.
9. Medication Summaries are printed nightly on the 11pm-7am shift
  • They are checked against the computerized MAR to ensure that all orders appear in the computer
  • They serve as backup for computer down-time. Allergies are to be printed in red in the upper right corner of the medication summary. The medication summaries are to be placed in the Physician Order section of the chart and the red Medication Summaries are to be shredded nightly.

Related Standards: