Nurse practitioners, in addition to completing the core PPR activities, must also complete a critical chart review.
Chart reviews provide an opportunity to review and assess the quality of client documentation against relevant standards of practice and entry-level competencies. As a key mechanism outlining client care provision, documentation indicates a licensee's knowledge, skill, and judgement; the care provided and actions taken to other health care providers; the provision of safe and appropriate care; and whether professional and legal standards have been met.
Critical chart reviews include the following components:
- Review of NP documentation in client medical record(s);
- Strategies for identifying and addressing documentation practices that require improvement; and
- Review of applicable standards of practice and guidelines.
Critical chart reviews may focus on a specific area of practice or look broadly across overall documentation. The intent is to identify strengths and opportunities for improving both the quality of documentation and the quality of care delivered.
NP chart review can also include a review of client documentation with a focus on evaluating client health-care management and outcomes against appropriate evidence. NPs should target practice areas related to diagnosing and treating, including prescribing, such as:
- A common and predictable diagnostic category in practice (different each year)
- A less common diagnostic category (different each year)
- Critical incidents in practice for the year