So, you're on the night shift, huh?
You’ve probably heard your Director of Nursing or Nursing Supervisor mention chart checks a time or two… or ten.
Let’s break it down, shall we?
A chart check is like the nightly audit of everything that went down during the day and evening shifts.
It’s your chance to make sure all the i's are dotted, and the t's are crossed.
This means reviewing orders, nurse’s notes, lab results, incident reports—the whole shebang.
And let’s be real, it might sound tedious, but it’s crucial for catching any errors before they become big problems.
Why Chart Checks Are Important
Your role in completing chart checks is to ensure that the information is not only complete but also accurate.
For example, let’s say a resident receives an order for Lasix 40mg daily with a diagnosis of congestive heart failure.
Your job is to ensure that:
The order was transcribed correctly.
The care plan includes a focus for congestive heart failure with appropriate goals and interventions.
There’s a nurse’s note documenting the new order and that the resident's representative has been notified.
The medication is actually available in the facility for administration.
Think of it like this: night shift is where you catch errors before they turn into bigger issues.
Suppose the Lasix order was accidentally transcribed as twice daily instead of once daily.
If you catch this during your chart check, you prevent a potential medication error. 🙌
How to Complete a Chart Check
So, how do you actually go about this chart-checking business? Here’s the lowdown:
Review New Orders: Start with any new orders entered during the day and evening shifts. If you’re using electronic orders, print out the order listing report for the specified dates. Cross-check to ensure the orders are transcribed accurately and reflected in the care plan.
Check Nurse's Notes: Ensure that the nurse's notes match up with the orders. There should be documentation stating the new order, including whether the resident’s representative has been notified and if there are any updates to the plan of care.
Lab Results: Go through lab results to make sure any abnormal findings have been reported to the provider and that there’s a note stating the provider’s response and any follow-up actions. Also, check if the plan of care has been updated accordingly.
Medication Availability: Confirm that any new medications ordered are actually available in the facility. Nothing says "oops" like realizing the morning shift can't give a med because it's nowhere to be found.
Incident Reports: Review any incident reports to make sure they’re complete and that the follow-up care plan adjustments are documented.
Relay Information: Once you’ve completed your chart check, make sure you have a process in place to relay this information back to the Director of Nursing or the appropriate person. This might involve leaving a note, filling out a specific form, or entering the findings into an electronic system.
The Night Shift: Keeping the Facility Compliant
So, if you thought night shift was just about handling the late-night snacks and keeping things quiet, think again!
This is where the magic happens.
By completing thorough chart checks, you’re ensuring that the facility stays compliant and that any potential errors are caught before they escalate.
You’re like the facility’s night-time guardian angel, catching mistakes before they even happen. 😇
Quick Recap
Chart checks are crucial for catching errors and ensuring compliance.
Your job involves making sure orders are accurate, care plans are updated, and the necessary documentation is complete.
Process the orders, nurse’s notes, lab results, and incident reports with eagle eyes.
Relay any findings to the appropriate person to keep everyone in the loop.
Remember, the night shift plays a vital role in maintaining the facility's compliance.
Next time you hear the words "chart check," just know you’re doing something incredibly important.
You’re not just filling in the gaps; you’re actively keeping residents safe and your facility compliant.
So, wear that night shift badge with pride because you are the backbone of the operation!
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