Doing An Awesome Chart Review

To get the most for the time you spend perusing a chart (i.e. medical record), try:

1) Reading over the entire discharge summary from the previous admission first, then take notes the second time around. Note major events whether or not they appear directly related to our field.

2) Note primary diagnosis (es) , date of onset, admission date, attending and referring physicians.

3) Note any previous speech pathology evaluations, treatments, notes, etc.

4) Review radiology reports on CT scans, MRI scans, etc.

5) Take a quick glance at labs.

6) Put the information all together in a succinct paragraph. Avoid abbreviations.