GENERAL NURSING POLICY AND PROCEDURE MANUAL Page 1 of 2 Title: Shift Review/12 Hour Chart Check
Policy No. MSD-19.16
Joint Commission Chapter/Section:
Effective Date: Nov 2012
Source (e.g. document, award, or committee, etc.):
Publication Status: New
L. Carroll, RN, Director, Professional Practice
6/05, 9/07
Cross-Referenced Policy No:
I.
II.
Revised Reviewed
X
Supercedes: NS-7.10
POLICY: 1.
A review of physician/practitioner orders will be done each shift to ensure that orders are recognized and transcribed appropriately, and that the necessary actions have been initiated.
2.
A shift chart check shall be done by the designated shift RN staff for the current shift or since the last chart check. This is to ensure all orders are addressed by the RN assigned to the patient. The review will consist of reconciling the current shift’s orders as stated below for paper orders by comparing the patient care orders, MAR (Medication Administration Record), and Computer Physician Order Entry (CPOE).
3.
Any order not signed off or transcribed incorrectly will be followed up with the Nurse Manager or designee and an incident report completed, if the omission or error resulted in a patient incident.
PROCEDURE: The RN will: 1. The following delineates the procedure to be followed in the shift review of physician’s/practitioner orders that are on paper: A. Review the following items on all orders and place a line under the set of orders and place signature with the statement “shift chart check.” B. The following items will be checked: 1. Recognition of the order by the licensed registered nurse with name, title, time and date in the appropriate space. 2. Orders signed, dated, timed and complete by physician/practitioner. 3. Telephone orders countersigned, dated & timed. 4. Orders correctly transcribed to the appropriate forms Medication Administration Record/MAR. 5. Correct transcription of medication orders to be renewed and/or discontinued. 6. Preoperative orders completed and/or discontinued post-surgery. 7. Transcription of laboratory tests, radiology, and diagnostic orders
verified in the computer using order inquiry function. Unacceptable abbreviations immediately clarified/corrected. Comparison of admitted medications to ordered medications (done only once after admission).
8. 9.
2.
For CPOE orders shift review consist of the following: A. Review the following items on all orders and check the line in the Electric Health Record (EHR) labeled “Shift Chart Check Performed”. This is your signature for completion. B. The following items will be checked: 1. Recognition of the electronic order for completeness. 2. Recognition of the electronic order for appropriateness for the patient. 3. Confirm correct modification of medication orders by Pharmacy (.e.g. adjustment of medication administration times). 4. Pre-operative orders completed and/or discontinued post-surgery. 5. Unacceptable abbreviations in the comments fields clarified/corrected. 6. Comparison of admitted medications to ordered medications (done only once after admission).
Approved by: CNO/Vice President – Patient Care Services Title Director, Professional Practice Title
Signature
Signature Origination Date: Supersedes Date(s): Reviewed Date: Revised Date:
6/05 9/07, 11/7/12 10/12
MSD-19.16
Page 2 of 2
11/7/12
Date 11/7/12
Date
