Nursing students: how to do chart review

本站添加: 2026-05-24

[00:00:00]If you are a nursing student going to clinical, you will likely have a nurse tell you to just go do some chart review. If you're anything like me, I had no clue what that really meant or how to do it. Here are some quick initial things that you should do. I've only ever used Epic, so that's what I will be talking about. On Epic, you will go ahead and open your patient's chart.

[00:00:18]Go to the notes tab. If you don't have a notes tab, you can go to the chart review tab, and then there's another tab that says notes. Within the notes, you can filter to the H&P. This is the initial history and physical. This shows you the admitting note from the doctor that admitted the patient. It tells you why they were admitted, what they looked like, their presentation, what the initial plan of care was, and any results that might have been added to the note. This tells you why your patient initially came to the hospital.

[00:00:47]Then you want to go and look at some of the recent progress notes. This gives you an idea of why they're still in the hospital, which sometimes is different from why they were admitted. I also like to always take a minute to look at the recent labs. You can access the labs through that chart review tab, under the little labs link, or there's typically a big tab that is called results review, where you can see labs, imaging, all of that good stuff. Then I would take a moment to look at order sets. This will tell you about lab orders, diet orders, respiratory orders, all of the things that you need to do throughout your shift with the patient. Start with that for now. This is going to give you a picture of why and when your patient was admitted, what they looked like upon admission, where we are at now, and what we need to do prior to discharging the patient. And then you also will feel a little bit less lost if your nurse just tells you to go do chart review.