3037 Chart Review

Georgia State Seal

Georgia Division of Aging Services
Public Guardianship for Adults Manual

Chapter:

3000 Case Management

Effective Date:

06/30/2023

Section Title:

Chart Review

Reviewed or Updated in:

MT 2023-03

Section Number:

3037

Previous Update:

MT 2022-01

Policy Statement

Public Guardianship Office staff shall review charts and other related documentation for each of the clients on their caseload at least once a month or more often, as necessary.

O.C.G.A. §29-4-22

  1. Except as otherwise provided by law or by the court, a guardian shall make decisions regarding the support, care, education, health, and welfare of the person under guardianship. A guardian shall, to the extent feasible, encourage the person to participate in decisions, act on his or her own behalf, and develop or regain the capacity to manage his or her personal affairs.

    To the extent known, a guardian, in making decisions, shall consider the expressed desires and personal values of the person under guardianship. A guardian shall at all times act as a fiduciary in the person’s best interest and exercise reasonable care, diligence, and prudence.

To make informed and prudent decisions, PGO staff shall review first-hand the following types of charts, notes, documentation, logs, etc.:

  • Charts and documentation located at the person’s place of residence, including:

    • Nursing home (NH)

    • Assisted living, personal care home

    • Group home

    • Host home

  • Other charts and documentation, including:

    • Day program

    • Physician office

    • Other health care professional

    • Hospital

Procedures

PGO Case Manager: When visiting a person who lives in a nursing home, assisted living facility, personal care home, group or host home, the case manager shall request and review the chart at least once a month.

If the visit is at the day program one month and the place of residence the next month, review charts and documentation at each visit regardless of location.

When looking through the chart for the first time, review the entire chart.

NH Chart

At a minimum, the case manager shall review the following items in the nursing home chart once per month. If the chart is a digital/electronic chart and the case manager is not allowed into the facility’s electronic files system, hard copies of the items below shall be requested.

  • Physician’s orders

  • Nurses notes

  • Medication

  • Incident reports

  • Results of tests performed since last review

  • Weight

  • Vital signs

Other Charts

At a minimum, the case manager shall review the following items in other charts, such as charts from a client’s day program or group, host or personal care home once per month:

  • Physician’s orders

  • Medication

  • Progress notes, including progress toward behavior support plan goals

  • Incident reports

  • Weight

  • Vital signs

If the person does not live in a facility or host home, request to see his or her prescription medication bottles and inquire about over-the-counter medications he or she may be taking. Contact his or her physician to request documentation after each visit.

Documentation

Performance of the chart review will be documented in the Division of Aging Services (DAS) data system for the appropriate client.

Example: “Reviewed Ms. Smith’s chart at her day program.”

References

O.C.G.A. § 29-4-2, et seq.