Chart Review

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Last updated 1:20 PM on 10/18/26
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9 Terms

1
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what is a chart review?

-review all info prior to interacting w/ pt

-done everyday before, but biggest before initial eval

-get picture of what going on and what got them there

-includes medical record

<p><strong>-review all info <em>prior</em> to interacting w/ pt</strong></p><p><mark data-color="purple" style="background-color: purple; color: inherit;">-done everyday before</mark>, but biggest before initial eval</p><p>-get picture of what going on and what got them there</p><p>-includes medical record</p>
2
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when do we complete a chart review?

  1. chart review

  2. patient interview

  3. assessment and interventions (combination first two)


<ol><li><p>chart review</p></li><li><p>patient interview</p></li><li><p>assessment and interventions (combination first two)</p></li></ol><p></p>
3
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what do we think is important to identify in the chart?

hospital, surgery, meds, age, accidents, family history, precautions

4
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purpose of chart review

-Gather current AND past medical history

  • diagnosis; medications; lab values and test

-Discover pt functional abilities

  • prior AND current social history

-Identify possible precautions and contraindications to PT eval and treatments

<p>-Gather current AND past medical history</p><ul><li><p>diagnosis; medications; lab values and test</p></li></ul><p>-Discover pt functional abilities</p><ul><li><p>prior AND current social history</p></li></ul><p>-Identify possible precautions and contraindications to PT eval and treatments</p>
5
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differences chart review approaches: IP vs OP

-OP: no lab values or imagining, especially if private practice; may have to request

6
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what info are we looking for and why?

-Tests and Interventions: tell us what can and can’t do

-Precautions/Restrictions: consistent documentation

-Contraindications: when can you not see patient

-Prior level of function: guides where want to go/expectation for discharge

-Current level of function

-Other relevent

<p>-Tests and Interventions: tell us what can and can’t do</p><p>-Precautions/Restrictions: consistent documentation</p><p>-Contraindications: when can you not see patient</p><p>-Prior level of function: guides where want to go/expectation for discharge</p><p>-Current level of function</p><p>-Other relevent</p>
7
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what info are we looking for and why? (part 2)

-past med history: inform how move currently

-current med history/diagnosis

-current meds: how react and take therapy

-current line placement: impact when want to treat pt that day

-order to PT

<p>-past med history: inform how move currently</p><p>-current med history/diagnosis</p><p>-current meds: how react and take therapy</p><p>-current line placement: impact when want to treat pt that day</p><p>-order to PT</p>
8
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what if the info we need isn’t present?

contact the right person! (don’t guess/infer)

<p>contact the right person! (don’t guess/infer)</p>
9
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how can we utilize our chart review info?

-inform the pt interview: guide what ask and what want to know

-confirm information already placed in chart

-assist in planning PT eval and treatment interventions

-have intelligent discussions with other healthcare providers