This chart review reference guide provides a general but also a comprehensive overview of what to look for in the patient’s chart and why.
In real-world practice, you may not need to nor have the time to review every single item. Use your clinical judgment based on the patient’s diagnosis, condition, etc. for what information to absolutely review and take notes on versus what to skip.
- Does the patient have orders for an OT evaluation from a physician?
- Is there even a documented order at all in the system? (Sometimes doctors forget to include it in their order set or misclick even though they intended to order OT.)
- Are the order’s current and active or have they expired?
- Can you take telephone orders? See company policy.
- Are there discharge orders?
- Is the patient even still in the hospital system or have they been discharged? You don’t want to waste time conducting a complete chart review only to find out they have been discharged or are going to be discharged by the time you see them (have discharge orders).
- Are there additional specific OT orders? E.g., exercises, splinting, PAMs, home assessment, etc. besides a general OT evaluation? Be sure to include these types of assessments/interventions in the plan of care.
- Although it may seem early, is there any mention of a discharge plan thus far? (Check the chart to see if there are already any notes from case managers.)
- This will give you an idea of the patient’s length of stay [time] in acute care and where [setting] they may be anticipated to go afterward.
- This also potentially affects your plane of care and your OT interventions.
- See what other orders were ordered, such as labs and tests. As there may be pages and pages of orders, pay special attention to the active orders.
- This can provide a lot of information on what is going on with the patient.
- Examples include imaging (CT, MRI, Xray), venous duplex (for DVT and PE), swallow studies like Modified Barium Swallow (MBS), lab draws (pretty routine), blood transfusions, or even planned elective surgeries may be placed as an order depending on your EMR system.
- Who was the hospitalist who ordered OT or who ordered OT? You’ll often need to write them down to include in your eval note.
- Do they have a sitter? (Psych patient = take safety precautions such as the use of materials and equipment.)
Placed by the OT who does the initial evaluation, then upon re-assessment. May be changed/updated at any time based on the patient’s status and need. See facility policy.
- Active or expired?
- Frequency and expiration date appropriate?
- Duplicates – there should only be one OT order active.
Demographics and Important Background Information
If time allows, it may be worth looking into the patient’s demographics and relevant information to give you an idea of things like:
- Name (mandatory) – watch for name alerts and people with the exact same names on the same unit. Verify patient’s identity at the bedside, e.g., armband & birthday.
- Age (write this down) – might clue you in on whether they may be retired, working age, minor, etc.
- Gender (write this down) – may let you know how to address them such as with pronouns. They may also be transgender.
- Race – provides insight into the client’s personal contexts, culture, disease risk factors, etc.
- Where do they live, e.g., city, rural? Visiting from out of town and had an emergency; foreigner? What services can they get there upon discharge?
- Single or married? Married means they likely will have a caregiver. Widowed/widower?
- Emergency contact – potentially their caregiver; who you likely will provide caregiver training (do not assume though).
- Language(s) spoken – so you can get a live/phone/video translator ready ahead of time to be efficient.
- Insurance – Medicare? Medicaid? Both? Private? Worker’s Comp? VA? – this gives you an idea of DME and also their potential discharge locations.
- Code status: DNR? Is there a POLST on file?
- (DNR guides Emergency Medical Service (EMS) providers and can give EMS permission not to perform cardiopulmonary resuscitation (CPR), whereas a POLST might include a DNR instruction regarding CPR, but provides more instructions regarding additional medical interventions.)
- BMI – may inform you that patient is obese/morbidly obese, in which case you may want to grab bariatric equipment such as a wheelchair ahead of time, hoyer lift, ask for additional help.
- Blood type – this is not as relevant for OTs.
- Allergies – good to know in case there’s a food allergy or other relevant allergy; not always just medications are mentioned under this. Sometimes patients are allergic to materials like latex so this is good to know ahead of time.
- NKDA = No known drug allergy
- Past surgeries – some could be recent, in which case they may still have precautions.
- Medical conditions (past medical history aka PMH) – write down the most important ones, not everything is necessarily relevant for OT.
- Cause of admission (“chief complaint”) – multiple physicians may write their own version or copy and paste what caused the patient to be admitted to the hospital.
- Start with the ED note if possible., but these may be vague as the team may not have gathered much information, e.g., patient was unconscious and came to.
- Different physicians (e.g., surgeon vs. specialists vs. hospitalist) may focus on different parts of the story.
- Try to read multiple notes to get a comprehensive picture of the patient’s reason for admission to build your occupational profile.
- Diagnosis – this may not be explicitly stated in the chart. You may need to do some inventive work and look around physician’s notes to find one. There may be multiple (or a list of) diagnoses. Use your best clinical judgment for what to list as the primary Dx.
- Sometimes, physicians may just not know what the diagnosis is and the pt is of unknown etiology and there are multiple “rule outs” for differential diagnoses. In this case, doctors use general terminologies rather than specific medical conditions. It’s not a major deal if you get it wrong in your chart, as the doctors don’t know either!
See Precautions Reference Guide for information on specific precautions (your facility’s precautions may be different than mine).
- Often can be found in physician’s notes or surgeon’s notes.
- May have to dig around to find them, such as in the surgery log/note.
- If the patient was transferred from another facility, their intake and admissions packet may mention the precautions.
- If PT has seen the patient, check the PT eval (but don’t assume it’s always correct.)
- May not be mentioned, in which case you may need to contact the physician or have the nurse verify it before you see the patient.
- Do some surgeons, e.g., orthopedics, have specific protocols, e.g., shoulder ROM exercise protocols?
- Pay attention to standard precautions versus the need for additional PPE, e.g., droplet, airborne, etc.
- Often posted at the door. Another clue is the presence of equipment carts for PPE. Third clue is where the room is located and the type, e.g., (-) and (+) air pressure rooms such as for COVID-19.
- Affects how you will plan your day and the order in which you may see your patients. For example, you would not want to see a COVID-19 (+) patient before you go to see an immunocompromised one and it would be better to switch them around the other way.
- Dysphagia? See SLP notes, NSG (nursing) notes, or the sign posted at the patient’s bedside.
Lab Values and Imaging Reports
- Look for trends in lab values (trending up? down? can’t tell?)
- Any critical lab values that may be a potential HOLD for therapy?
- Be sure to read the conclusion in the relevant imaging reports, e.g., “PT is (+) for DVT.” “(-) for COVID-19.” “Cardiac output is…”
- This is often written concisely at the bottom of the imaging report in easy-to-understand language.
- It may be helpful to look at the actual image slides, e.g., X-rays for fractures upon ER admission, post-surgical ex-fixes, intramedullary nailing of the femur (IMN), STAT imaging orders for acute changes, e.g., second CVA, DVT/PE.
Look for human errors. Sometimes the team enters an extra digit and it may set off a red flag, but in reality, it’s just a typo. And some EMRs allow you to carry over data from the previously charted vital sign, e.g., respiratory rate. If a vital sign like respiratory rate stays unchanged, this is likely a copy and paste data point(s) and you check this yourself at the bedside.
This is also why spotting trends can be important to see if a patient is improving or potentially going south.
- Blood pressure [BP] (Orthostatic hypotension)
- Heart rate/pulse rate [HR] (MET values; orders for specific tachycardia limit? A-fib?)
- Respiratory rate [RR] (on room air or supplemental O2?)
- Temperature [Temp] (documented in Celsius; running a fever?)
- Pain (1-10), Visual analogue scale – controlled?
- Weight (usually taken by CNAs, RNs) – dietician referral?
Medications can provide a lot of information about the patient, such as their chronic health and their acute health history. While memorizing and knowing all the Rx is not required, it is helpful to look into the purpose, route, timing, and side-effects of the most commonly ordered ones.
- Current medications, including ones to manage pain?
- Last dose for pain management? May need to coordinate with nursing for the timing of OT evaluation.
- Most patients have multiple medications available to them to manage their pain. Some are scheduled and some are as needed (PRN).
- Some helpful Rx for pain may not have been ordered – you along with PT may need to advocate for the patient if you are to mobilize them out of bed. This is commonly needed in the ortho unit.
- Consider the side effects and risks with medications such as increased fall risk, decrease mentation, vital sign changes, and increased risk for bleeding (including internal hemorrhages – which you cannot see).
- Are any Rx contraindicated for mobilizing out of bed? E.g., DVT prophylaxis less than 24 hours = HOLD. See facility policy.
- Diabetes medication, e.g., insulin? Do not work on feeding with the patient; check in with the nurse first.
- Route of Rx? Provides clues of potential lines and peripherals that pt may have (and what to be cautious of when mobilizing out of bed).
- May provide clues of potential dysphagia, e.g., “crushed pills”.
- Physicians, Surgeons, Nurses, Case Managers, Social Workers, Mental Health, Physical Therapists, Speech-Language Pathologists, Respiratory Therapists
- OT – obviously. 🙂
- Read the most up-to-date progress notes if time does not allow a comprehensive review.
- Note that some people copy and paste notes or just add to the bottom.
- If PT already evaluated the pt, read this note and their progress notes too. Avoid asking the same questions if they were asked already, e.g., stairs, to show the strengths of being an interdisciplinary team.