Instructions for Chart Review Tool by benbrown

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									                            Instructions for Chart Review Tool

Note: Most of the information needed to complete the Chart Review Tool can be found in
the physician orders, Med Sheet (MAR), Care Plan, or 24-hour report sections. You may
also have to look in the Nurse’s Notes section. Instructions for each question below
provide recommendations for where to look in the chart to find the necessary
information.

Question                        Instructions for Each          Data Source
                                Chart Review Tool Item
  Identifying Information       Write in the name of the
                                facility (or a code that you
                                designate for the facility),
                                the chart review date (i.e.,
                                date chart was abstracted),
                                admission date, assessment
                                reference date (ARD),
                                resident’s social security
                                number, state of resident’s
                                cognitive ability (intact or
                                impaired), resident’s
                                gender, and resident’s
                                DOB.
             1                  Check the frequency and        Sections J2a and J2b of the
                                intensity with which the       most recent MDS
                                resident complains of or       assessment.
                                shows evidence of pain, as
                                indicated on the most recent
                                MDS.
             2                  Check whether there has      Physician orders, 24-hour
                                been a documentation of a    report, or nurse’s notes
                                visit and/or a staff         section of the chart from the
                                notification of DM, NP, or   10 days of the most recent
                                PA during the most recent    MDS assessment period
                                MDS assessment period or     (i.e., the 7 days of the look-
                                the 3 days following the     back period, plus the 3 days
                                ARD                          following the assessment
                                                             reference date).
             3                  Check whether the            24-hour report or nurse’s
                                resident’s pain has been     notes sections of the chart
                                assessed using a pain        from the 3 days following
                                intensity scale during the 3 the most recent MDS
                                days following the           assessment reference date
                                resident’s most recent ARD. (ARD)
             4                  Check all of the pain        24-hour report or nurse’s
                                symptoms that were on        notes sections of the chart
        the most recent MDS.        from the 3 days following
                                    the most recent MDS
                                    assessment reference date
                                    (ARD)
5a/5b   5a.    Check whether the    Med sheets from the 10
               resident has had any days of the most recent
               pain medications     MDS assessment period
               during the most      (i.e., the 7 days of the look-
               recent MDS           back period, plus the 3 days
               assessment period or following the assessment
               on any of the 3 days reference date)
               following the ARD.
        5b.    List the pain
               medications written
               on the med sheet
               during the most
               recent MDS
               assessment period or
               any of the days
               following the ARD.
               Then check whether
               it’s a WHO II or III
               med, list the med
               dose and frequency,
               circle the schedule
               of the med, and
               check whether there
               has been a change in
               the medication over
               the last 10 days.

 6      Look for documentation of     24-hour report or nurse’s
        a complete pain assessment    notes sections of the chart
        completed during the most     from the 10 days of the
        recent MDS assessment         most recent MDS
        period or on any of the 3     assessment period (i.e, the 7
        days following the            days of the look-back
        assessment reference date.    period, plus any of the 3
        Check ‘Yes’ or ‘No’ to        days following the
        indicate whether or not all   assessment reference date).
        of the elements of a pain
        assessment was assessed.
 7      Look for documentation of     Care plan, physician’s
        whether non-drug therapies    orders, or nurse’s notes
        were part of the plan of      sections of the chart form
        care during the most recent   the 10 days of the most
MDS assessment period or      recent MDS assessment
on any of the 3 days          period (i.e., the 7 days of
following the assessment      the look-back period, plus
reference date. Use the       the 3 days following the
table of non-drug therapies   assessment reference date).
on the Chart Review Tool
as a reference list.

								
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