Chart review steps

Question 1

Chart review steps for patients

Answer 1

1. Start with notes
   - Start at the beginning
   - review H and P is a big one
   - look for cardio consultant
   
   • Check assessment and plan
     - Look for nephrology consult (this is for the kidney)
2. Then go to results review
   - check labs

3, Orders
- Active
Look for consults and referrals
- The big consults we are looking for are Cardiac consult, neurologist, podiatry, ortho (would just say orthopedics

4. Chart review
   - Imaging
5. Summary
   -Systems review
   - Look at vitals and oxygen
   - Then look at lines and tubes