Medical Record Audit

By DISC Corporation | November 28, 2022

In today’s digital healthcare environment, nearly every element of patient care is connected to your electronic medical record.

And by now, we all know the benefits. EMR and EHR systems equip providers with up-to-date patient information at the point of care – helping to improve care coordination, communication and efficiency. 

That all sounds great on paper. But in reality, many organizations are up against a serious problem: Medical record chart errors. Because regardless of which EHR software you use, a patient’s chart is only as useful as the information it contains.

Medical Record Chart Errors Are More Common Than You Think

Everyone knows chart errors exist. Whether you work in patient care, health information management (HIM) or an administrative role, you likely come across errors in a medical record chart on a fairly regular basis. But recent data suggests the problem may be worse than you may think.

A 2020 study published by JAMA Network Open found that 21% of surveyed patients found mistakes in their medical record chart. And of those patients, 42% said the mistake found was either somewhat serious (32%) or very serious (10%).

These types of chart errors leave both providers and patients at risk. That’s why we recommend that organizations regularly conduct their own internal patient chart audit.

Why Should I Audit My Medical Records?

Auditing your medical records is a great way to not only catch errors, but to identify entire HIM processes that need improvement. Here are five reasons why you should add regular medical record chart audits to your to-do list:

  1. Accuracy. Improving the accuracy of your medical records is one of the most important benefits of conducting an internal patient chart audit. That’s because medical record chart errors can directly impact patient care. If a document is filed incorrectly, a provider may not be notified that follow-up is required. Or, if a document is filed to the wrong patient chart, it may result in a HIPAA privacy violation.
  2. Compliance. Every type of patient record has its own documentation requirement. By identifying process failures, such as late indexing or filing, you can make adjustments to help ensure your medical records remain compliant.
  3. Standardization. For health systems and providers working out of multiple locations, it’s not uncommon for patient charts to be handled differently from office to office. Regular patient chart audits can help you identify these discrepancies – allowing you to develop standardized processes across your organization. When processes are standardized, providers can quickly find patient data because it’s consistently filed in the same location and labeled the same way every time. Standardization also allows you to pull comprehensive reports on specific documents.
  4. Efficiency. By taking a closer look at your medical records, you can uncover opportunities to save time and improve workflows related to indexing and filing. You may be surprised to see how a few small process changes can reduce medical record chart errors – while making life easier for providers and support staff.
  5. Cost-savings. What do accuracy, compliance, standardization and efficiency have in common? They all contribute to a healthier bottom line for your organization. Better data translates to better patient care and improved outcomes – while process improvements can help save time and money.

How Do I Conduct A Medical Record Chart Audit?If you’re interested in conducting your own medical record chart audit, DISC Corporation can help. Our free Patient Chart Audit Guide offers step-by-step instructions on how to conduct your own internal audit. You’ll learn what steps to take in a successful audit, the typical problems you’ll encounter (and why), along with actionable tips to help you at each stage. We even include an outpatient chart auditing template for you to use – so you can get started right away.


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