As this is a documentation review, you will need to work with your employer (and IT department if applicable) to provide your assessor with access to your client records. It’s a good idea to secure this access as soon as possible after your review date notification as it can take some time, and you don’t want your review to be delayed.
Also, please ensure your chart access arrangements for your assessor comply with your organization’s health records, information management and information privacy and security policies. For example, your employer may require that the assessor sign a confidentiality agreement prior to the review or acquire training and password access to your EMR.
In preparation for the review you will need to identify and arrange to have 30 complete and randomly selected patient records pulled of patients you’ve seen and cared for in recent months.
The assessor will then select 10 charts to review.
If you use an EMR, you can provide the assessor with a day list/schedule from which he or she can randomly choose 10 charts to review. Ideally the list will include the client’s age, gender and presenting complaint. The assessor will require "read only" access to the EMR.
If you use paper charts, please arrange for 30 charts to be randomly selected and available on the review day—the assessor will select the 10-chart sample from these to review. (If you have fewer than 30 charts, don’t worry; just pull all the charts you have.)
If you use a combination of both EMR and paper charts, complete client records are required so the assessor will need access to both, including any prescribing activity.
A review of your client prescriptions is always included. If you are prescribing controlled drugs and substances with controlled prescription program duplicate pads you must provide no fewer than three charts with these type of prescriptions.
The assessor will endeavor to review charts that represent the breadth of your practice e.g., age, gender, chronic disease, episodic care, wellness care, etc.
Your charts will be reviewed using a
Chart Review Guidelines (PDF) based on the indicators related to BCCNM Standards of Practice, the
NP Scope of Practice and Entry-level competencies for NPs in Canada. You may find it helpful to review this tool prior to your assessment.
Please contact BCCNM with any questions or if you need assistance