Patient Chart Review: A Guide to Ensuring Patient Safety

Patient safety is the number one concern for medical personnel. Reviewing a patient's chart should ensure patient safety.

Instructions

• 1

  Retrieve the patient chart and read from the upper left hand corner across, verifying that the chart is for the patient you are to provide care for by validating the patient's name, date of birth, social security number and insurance numbers. Confirm information with the patient.

• 2

  Continue to read the next section, verifying all allergies and adding any that are not listed to the chart.

• 3

  Identify all diseases and diagnoses for the patient prior to performing a procedure, adding any that are not listed.

• 4

  Complete the patient chart review by rereading the chart to identify any missed information that could be detrimental to the patient.