Women's floor chart reviews - how often do you review?
Hello all!
We are in the process of expanding our CDI program to include NICU/Peds/L&D/Postpartum. We are starting to review the charts to look for query opportunities and issues that will need to be addressed. But the one thing our CDS on that floor is finding is that there are a LOT of healthy charts that really don't need to be reviewed for moms as well as babies. (this is primarily on the L&D and postpartum floors). So I wanted to found out if anyone has a system on how to go about reviewing the charts on these floors? Is it just reviewing the census and admit status to find out the PDx? Is it meeting with the leads to find out who is high risk or has issues? What is the best way to "weed out" the healthy moms and babies and get to the charts that really need to be revieiwed? I certainly do not want to spend time reviewing each chart to find out which charts really need to be reviewed! (if that makes sense). Our current review system does not have the ability to pull this information for us, so I was just curious as to how others are handling this? Any thoughts or feedback would be great. Thank you!
Rebekah Foster, RN CCDS
Kaweah Delta Medical Center
400 W. Mineral King
Visalia, CA 93291
559-624-5085
rfoster@kdhcd.org
We are in the process of expanding our CDI program to include NICU/Peds/L&D/Postpartum. We are starting to review the charts to look for query opportunities and issues that will need to be addressed. But the one thing our CDS on that floor is finding is that there are a LOT of healthy charts that really don't need to be reviewed for moms as well as babies. (this is primarily on the L&D and postpartum floors). So I wanted to found out if anyone has a system on how to go about reviewing the charts on these floors? Is it just reviewing the census and admit status to find out the PDx? Is it meeting with the leads to find out who is high risk or has issues? What is the best way to "weed out" the healthy moms and babies and get to the charts that really need to be revieiwed? I certainly do not want to spend time reviewing each chart to find out which charts really need to be reviewed! (if that makes sense). Our current review system does not have the ability to pull this information for us, so I was just curious as to how others are handling this? Any thoughts or feedback would be great. Thank you!
Rebekah Foster, RN CCDS
Kaweah Delta Medical Center
400 W. Mineral King
Visalia, CA 93291
559-624-5085
rfoster@kdhcd.org
Comments
Kathy Shumpert
We review all vaginal deliveries that stay past 48hrs, C-sections and NICU babies only. We have found that normal deliveries are usually d/c by 48 hrs. The CDI also sits beside the case manager and is informed of any complicated cases.
Hope this helps!
Thanks,
Linda
Linda Rhodes RN, BSN, CCDS
Manager Clinical Documentation Improvement
New Hanover Regional Medical Center
Wilmington, North Carolina
Office # 910-815-5544
Cell " 910-777-8344
e-mail : linda.rhodes@nhrmc.org