Chart Review Directions

Chart Review #2:

Select a medical record from the Example Medical Records module (located at bottom of the Modules page) and review all documents within the record. Create a PowerPoint presentation with voiceover on each slide that guides viewers through the patient’s chart. Submit your presentation as a PowerPoint file (do not convert to PDF as you will lose your voiceover).

Your PowerPoint must include at minimum:

• Chart ID (use file name – if this is missing, I will not grade and you will receive a zero for the entire review!!)
• A brief summary of the patient (demographics)
• History of present illness
• Information from progress notes (how did the patient’s hospital stay go)
• Information from orders (what types of medications and other treatments were ordered)
• Description of treatment given, including therapy and/or (operative) procedures
• What did the pathology show if a specimen was removed?
• Was the patient discharged to home or another location? 
• What was the final diagnosis?

Your voiceover must add substantial information beyond what is on the slides – do not read directly off the slides as you will lose points! If your presentation does not include voiceover, you will receive a zero!

• Face Sheet
• ER Record
• Discharge Summary
• H&P
• Progress Notes
• Orders
• Operative Report
• Pathology
• Medications
• Graph
• Nursing Assessment & Notes
• Discharge Assessment

• Face Sheet
• ER Record
• Discharge Summary
• H&P
• Progress Notes
• Orders
• EKG
• Medicaton
• Graph
• Nursing Assessment & Notes
• Discharge Instructions

• Face Sheet
• Discharge Summary
• H&P
• Consultation
• Progress Notes
• Orders
• EKG
• Lab
• Medication
• Nursing Assessment & Notes

• Clinical Resume
• H&P
• Consultation
• Progress Notes
• Orders
• Cardiac Cath
• Operative Report 1
• Operative Report 2
• EKG
• Radiology
• Laboratory
• Medication
• Nursing Assessment & Notes
• Discharge Instructions