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Chart Review Guidelines

Chart Review Guidelines

Below is what you'll need to have prepared for the site visit.

Deaths

  • Death summary and any critical progress notes

  • Autopsy report and conference notes (including critical discussion) 

  • Show loop closures, if applicable

Transfers

  • All pertinent progress notes, indicating the reason for transfer, and discharge summary

  • Discussions of transfers

Non-Fatal Complications

  • Discharge summary and critical progress notes

  • Summary of conferences including critical discussion

  • Show loop closures, if applicable

Non-Fatal Rehabilitation          

  • Prepare a rehab case including specific complications and must describe how they were managed by the multi-disciplinary team. The reviewers will be looking for evidence of excellence of care along the entire continuum.

  • The purpose of the rehab case is to highlight the multidisciplinary approach. The goal is to shine a light on how well therapy and surgical efforts are coordinated.

    • The ideal case might be a big Burn who developed an early contracture while still in the hospital and waiting to go to rehab. The therapist tried multiple types of splints and then ultimately the team decided there was a need for an early release in graft.

    • It could be a patient that was sent to a SNF and then brought back once they had gained a little more strength. The idea is to try to give an example of how well the rehab team and the acute care team work together to assist in recovery.

Adult & Pediatric Burn Centers

  • Must prepare at least one pediatric case

Other Items to Keep in Mind

  • Reviewers may reach out ahead of the visit to provide some insight into specific areas they plan to focus on. For example, if they noted a case where a patient passed away due to an endotracheal tube (ETT) being placed in the esophagus, they might ask you to review the chart beforehand and identify any documentation that supports or challenges that assessment. This approach helps keep the review focused and potentially more efficient.

  • It is beneficial to designate someone in advance to help reviewers navigate any electronic records or find any information the reviewers might request during the review process.

  •  A single patient’s medical record may fulfill more than one of these categories. Patients whose treatment involved the quality assurance program should receive priority for selection. This latter criterion will facilitate the evaluation of the quality assurance program for the unit. Please have all quality assurance materials available for the medical records review.