Instructions for Chart Review Tool
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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.