Skip to main content

Preparing for review

Patient records selection for the NP Onsite Peer Review

Access to patient records

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.

Preparing patient records

Our goal is to work collaboratively with you to obtain access to your client records. When scheduling your review, we will discuss with you the specifics of your charting system and establish a plan to obtain access on behalf of the assessor.

IMPORTANT:

  • 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.
  • On the day of the review, you’ll need to provide the assessor with an orientation to your charts (e.g., charting approaches in the practice setting, navigating the EMR to follow the client’s journey.)

Questions?

Please contact CRNBC with any questions or if you need assistance

 Questions?

Contact us:

Home > Practice support > Quality Assurance > Nurse practitioners > NP onsite peer review > Preparing for review