Sunday, October 18, 2009

Incomplete charts- Rich

I request that we educate the staff that charts are not broken down until the chart complete box is checked?
Anyone agree?
I also propose that we hold the bonus for anyone with more than 15 charts.
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4 comments:

  1. Peter BensonOctober 19, 2009 at 10:03 PM

    I agree.

    ReplyDelete
  2. ChristineOctober 20, 2009 at 1:31 AM

    I agree - no chart breakdown. I hate losing my charts. Agree on teh bonus thing too. However, if a pt elopes after PIT exam only, does that end up being an incomplete chart? Chad and I discussed this weekend. At my other site, if a pt elopes after PIT exam, the NP/PA go back and fill out the real chart as much as they can based on the limited PIT exam and any diagnositcs ordered with clear documentation about pt eloping prior to complete exam/eval. Should we be doing this? Is that where some of these uncompleted charts are coming from?

    ReplyDelete
  3. Mark GoldinOctober 20, 2009 at 8:44 AM

    Sounds like a good policy.
    If all charts were documented to a level 2 you would not have to worry. I would not take much time.
    I would appreciate a more clear statement on the chart from the pit in cases when there is not an obvious reason to send the pt to the core, eg peds fevers, teenage chest pain, ingestion of benign substance. We do read the notes so it also helps if it is legible.

    ReplyDelete
  4. UnknownOctober 20, 2009 at 1:18 PM

    Yes, midlevels should be filling out complete exams. We decided this 4 months ago, but for multiple reasons it is not getting done.

    This is not where the incomplete charts are coming from however.

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