What Should You Look for During a Chart Review?
When completing a chart review, it is important to review admission notes, recent notes from the attending/medical team and nursing, as well as any relevant imaging, lab values, medications, orders, current oxygenation needs (i.e. nasal cannula, high-flow, or mechanical ventilation), and what tubes, lines, or drains that may be attached to the patient. One way to structure and guide your chart view is “VITALS: A systematic approach to ICU chart review” as developed by Evangelist & Gartenberg (2016) and described both in AOTA SIS Quarterly Practice Connection and within the Intensive Care Unit chapter in Occupational Therapy in Acute Care, 2nd ed.
References
Evangelist, M., & Gartenberg, A. (2016, February 8). Toolkit for developing an occupational therapy program in the ICU. SIS Quarterly Practice Connections, 1(1), 20–22.
Evangelist, M., & Gartenberg, A. (2017). Vitals: A systemic approach to ICU chart review. In H. Smith-Gabai & S. E. Holm (Eds.), Occupational Therapy in Acute Care (2nd ed., pp. 130–131). AOTA Press. Reprinted with permission.