Chart Reviewing in Acute Care: Lessons from the Floor

One of the biggest skills I’ve been learning during my current acute care rotation is how to efficiently review a patient’s chart. It’s not something we get much structured training on in school, yet it’s one of the first (and most important) things we do before ever walking into a patient’s room.

By no means am I an expert, but here’s what I’ve learned so far about how to sort through the noise, find what really matters, and use it to evaluate and treat safely and effectively.

What’s Need to Know vs. Nice to Know

Chart reviewing can feel overwhelming when you first start. You open the EMR, and there’s a flood of labs, imaging, consults, and old notes waiting for you.
But not everything deserves your time right away. Here’s how I’ve started to separate the need to know from the nice to know.

Need to Know Information

Diagnosis:
This tells you what to look out for and gives a general idea of what’s going on. But diagnosis alone doesn’t tell the whole story, if you only focus on it, you risk missing important comorbidities or complicating factors. Always pair the diagnosis with a broader medical understanding of the person in front of you.

Current Major Limiting Issue:
Often this is pain, swelling, or fatigue. These are the barriers that limit participation in therapy and usually reflect the stage of healing the patient is in.
Because we’re in acute care, most patients are in the early inflammatory phase of recovery. That means our focus often shifts to reducing limiting factors (like pain, fear, or stiffness) to promote safe, meaningful participation.

Weight-Bearing and Activity Orders:
This one is small but crucial. Bones, ligaments, and muscles need time to heal, so when you see an orthopedic or traumatic injury, those orders are sacred. Follow them to the letter to protect healing structures and ensure positive long-term outcomes.

Precautions and Vitals:
Always check precautions (surgical, cardiac, sternal, spinal, etc.) and monitor vitals before, during, and after sessions. Know your facility’s cutoff scores for things like BP, HR, SpO₂, hemoglobin, and hematocrit.
If you’re not taking vitals, especially in medically complex patients, you can’t confidently say they’re safe to mobilize.

Comorbidities:
Almost every patient in acute care has multiple medical conditions. Longer lifespans mean more medical complexity. Understanding other common, major diseases like COPD, diabetes, or CHF allows you to adapt your treatment safely whether that means adjusting pacing, oxygen monitoring, or mobility goals.

Nice to Know Information

Environment/Home Setup:
Important for discharge planning, but not critical for day one. You can often clarify this in your subjective interview.

Prior Level of Function & Assistive Device Use:
Helpful context for goal-setting and functional expectations, but again it’s easy to gather directly from the patient or family during your initial encounter.

Medication Usage:
Nice to note if you’re seeing patterns (e.g., high pain scores despite opioids), but not something that needs deep review before seeing the patient. Many patients are on hypertensives, anti-depressives, and other meds for common conditions. Note these things and have a general sense of side-effects when the presenting condition is not following a typical pattern.

Imaging:
Good for confirming your suspicions or clarifying structural involvement, but rarely changes your initial treatment plan unless there are acute post-surgical or fracture findings.

In short: these are all important, but they can be confirmed quickly through conversation. The goal of a chart review isn’t to memorize everything, it’s to enter the room informed, safe, and ready to move.

Building Your Own Review System

Having a system will make you infinitely more efficient. A consistent method helps you collect key information quickly and start building mental “shortcuts” for navigating your facility’s EMR.

Standardization = less time clicking and more time critically thinking.

Ask yourself:

• What information do I absolutely need before seeing any patient?

• Where is that information found in the EMR?

• In what order do I check it?

Once you’ve answered those questions, you’ll start to develop your own repeatable workflow.

What works for me:

1. Start with the earliest note — This gives context on why the patient was admitted, how acute their condition was, and what initial orders were established.

2. Check the most recent physician note — This shows current medical stability, any new findings, and overall progress.

3. Read the latest PT note — This helps me see what’s already been done, how the patient responded, and where I can progress from there.

4. Review current physician orders — Verify weight-bearing restrictions, movement precautions (e.g., sternal or posterior hip), and diet/NPO orders for safety.

5. Check nursing notes — These often contain valuable details about lines, drains, or mobility permissions (e.g., “okay to ambulate with telemetry”).

6. Glance at recent medications — Especially for pain control. Knowing when a patient last received pain meds helps you time your session for optimal participation.

This system keeps me efficient and ensures I’m walking into each room prepared and safe.

Knowing When to Ask Questions

Even with the best system, you’ll run into confusing abbreviations, conflicting notes, or orders that don’t make sense. When in doubt, ask.

Each facility and provider has their own shorthand. Clarify early what abbreviations mean and how to filter different provider notes (nursing, physician, case management, PT). Most EMRs let you sort or filter note types, use that to your advantage when hunting for specific info.

The more you understand the EMR structure, the faster and safer your decision-making becomes.

Parting Words

Chart reviewing is a skill that takes time and repetition. At first, it feels like trying to read a novel written by twelve authors at once but with practice, you start to recognize patterns and know where to look.

Give yourself time to develop your own process. Focus on what’s need to know versus nice to know, create a consistent workflow, and don’t be afraid to ask questions when something doesn’t add up.

Disclaimer

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.