By Tiffany Lai July 17, 2023
Here are some important steps to chart reviewing.
1.) Check to see that there are active OT orders from the doctor before seeing the patient.
2.) Why is the patient here and what did the doctors do or what are they doing to address it?
- Sometimes doctors are still working up a diagnosis or the patient has not yet received their procedure. It is preferable to see the patient after they’ve been treated.
3.) What comorbidities or medical history does the patient have that will impact your session?
- Any recent surgeries, history of stroke with residual deficits, amputations, parkinsons etc.
4.) What precautions does the patient have?
5.) Check at least the last few days of notes
6.) What is their AMPAC score? (This is a score reflecting how mobile the patient has been with nursing)
- Has PT seen this patient yet?
- As a bonus, if the patient has past rehabilitation notes, you may be able to see their level of independence after the previous discharge.
7.) Check their most recent vitals and their blood test for out of range values.
This is a very basic chart review. Different diagnoses has specific medical information that is important to chart review.
Based on the information you have gathered, formulate a tentative plan for your treatment session. This may have to be adjusted as you first start seeing how the patient moves.
Things to think about:
- What is the relevant patient education or precautions that needs to be reviewed?
- How should the patient be mobilizing according to their precautions?
- What do you anticipate their level of assistance to be?
Talk with nursing about a good time for your session and check with the patient if pain meds are needed prior to session.
- If the patient needs pain medicine, medicate and wait 30+ min for medicine to take effect.
- Grab all needed ADL items.
- If the plan is to wheel or walk through the hallway, make sure to bring a gown to cover the patient’s bare back.