Chart Review

What it is

Chart Review gives you a full patient chart and four jobs. First, Find: open each tab (vital signs, labs, MAR, nurse's notes, provider notes, and history) and tap anything abnormal or concerning, including orders that were never carried out.

Then Map: pick the priority problem and the findings that support it (some abnormal findings are real but unrelated). Then Call: build an SBAR call by picking the most specific, useful statement for each part. Then Recommend: select every nursing action that applies, and unsafe choices cost points.

At the end you see your score, the finished concept map, and the ideal SBAR call. Patients range across ages, and kids and pregnant patients have different normal ranges, so watch trends, not just numbers.

What you'll learn

• How to scan a chart for abnormal findings and missed orders
• How to read trends, not just single values
• How to pick the priority problem and support it
• How to build a concept map
• How to give a clear, specific SBAR call
• Which nursing actions are safe and which are not

How it helps you

NCLEX tests clinical judgment, using NCSBN's Clinical Judgment Measurement Model. Every NURSYN game is built on the nursing process. Chart Review works these ADPIE steps: Assessment, Diagnosis, Evaluation.

• Covers Assessment, Diagnosis, and Evaluation: find the data, name the problem, check the plan
• Every step maps to the NCJMM from recognizing cues to taking action
• SBAR practice follows the AHRQ TeamSTEPPS tool
• Concept maps are the same thinking your care plans require

How to play

1. Pick a chart
2. Find: tap every abnormal finding and check your work
3. Map: choose the priority problem and the supporting findings
4. Call: build the SBAR
5. Recommend: pick the nursing actions, then review your results

Clinical topics covered

Sources

The clinical content and the teaching approach behind this game line up with these references.

1. TeamSTEPPS Tool: SBARAgency for Healthcare Research and Quality (AHRQ). How care teams use Situation, Background, Assessment, and Recommendation to communicate about a patient.
2. How to Understand Your Lab ResultsMedlinePlus, National Library of Medicine. What reference ranges are and why they vary from lab to lab.
3. NCSBN Clinical Judgment Measurement ModelNCSBN. The framework NCSBN uses to measure clinical judgment and decision making on the NCLEX.
4. The Nursing ProcessAmerican Nurses Association. Assessment, diagnosis, outcomes and planning, implementation, and evaluation.