09 February 2012
print version

Recording internal credits e.g. what constitutes a Chart Review?

A chart review could mean a number of things:

  1. Reading through a patient's chart and summarising past history and medication. So that someone new picking up the chart has an easier task of continuing with that individual's care. Or indeed reminding you of a past event that you had forgotten or neglected to include in the existing summary.
  2. Reviewing the chart and ensuring that best practice/guideline was adhered to (almost a mini audit) One could pick 5 diabetic patient's charts to review.
  3. As part of deciding why something went badly (or well) as an element of a significant event analysis, one might review the consultation notes over a number of consultations.

One way of summarising "chart review" would be that you review the patient without him/her being there.