If you’re reading this blog post, you already know the benefits of conducting a patient chart audit. So we’re going to focus specifically on how to record and analyze the results of your audit using DISC Corporation’s patient chart audit form.
Step 1: Download the Patient Chart Audit Form
This Microsoft Excel template is available as a free download when you sign up to receive our Patient Chart Audit Guide. We created this valuable tool as a resource to help you:
- Record data: Use the template to directly enter document audit data from your electronic medical record.
- Track errors: Fields in the “Audit Data” tab prompt you to verify the accuracy of each record using a simple dropdown menu.
- Generate reports: Using the “Audit Report” tab, you can automatically calculate the results of your audit. The patient chart audit form will calculate audit statistics and error rate percentages.
- Identify problem areas: By calculating the frequency of each error type, you can uncover the most common errors in your EHR.
If you haven’t downloaded our patient chart audit form yet, visit this page to submit your contact information and get instant access to the template. Then, follow along as you read the rest of this post.
Step 2: Prepare For Your Audit
Since the goal of your audit is to uncover errors and inconsistencies, the scope should be large enough to serve as a representative sample of your organization’s patient population – but not so large that the audit process becomes overwhelming. Here are a few tips for determining your audit scope:
- Sample size: When auditing patient charts, we recommend examining a minimum of 1,000 documents. This should provide you with enough information to discover patterns in the medical record indexing and filing.
- Random sampling: To get a representative view of your medical records, choose a random sampling of patient charts for your audit. You can do this by starting with a specific last name or letter. Then, work through your patient database alphabetically until you’ve audited 1,000 documents.
- Length of time: If this is your first audit, review documents that have been filed within the past year. After that, you can conduct quarterly audits where it will only be necessary to review documents filed in the last three months.
Before starting your audit, you may also want to enlist your HIM team or medical records manager. They may be able to provide best practices for accessing charts during the audit process.
Step 3: Record Document Data
Open the patient charts that fall within the scope of your audit and use the “Audit Data” tab of the patient chart audit form to record the results of your audit. For each document you open, enter data from your EHR in the following fields, using one line per medical record:
- MRN: Enter the medical record number (MRN) assigned to the document in your EHR system.
- Document Type: List the type of document filed in your EHR. Some examples include lab results, procedure notes, outside records, imaging reports, correspondence, and HIPAA forms.
- Description: Add the document type description from your EHR for the document being reviewed. For example, if your image report is an X-ray and X-Ray is in the document description field of your system, add that detail to the description field in the tracker.
- DOS: Enter the date of service for the record.
- User: List the username of the person that indexed the document. Including this data can help address errors that may be specific to an individual provider or staff member.
Step 4: Record Audit Data
After entering the document data from your EHR, evaluate the accuracy of the information entered for each medical record. If you’re using DISC’s patient chart audit form, use the dropdown menu in each cell to select “correct” or “incorrect” for each of the following fields:
- Patient: Verify that the patient name in the document you’re auditing matches the name in the electronic chart.
- 24 Hour: Check the filing date and time to see if the document was filed to the patient chart within 24 hours of receiving it.
- Separation: Confirm that all pages within the document belong to that document and there are no missing pages.
- Doc Type: Review the content in the document you are auditing to confirm the correct system document type was assigned.
- Desc: Review the content in the document you are auditing to confirm the correct system description was assigned.
- DOS: Ensure that the date of service in the document matches the medical record entry.
- Provider: If the document type you are auditing should be sent to the provider for review, verify that the provider name in the document matches the provider who reviewed the document.
- Sign-Off: If the document type you are auditing should be sent to the provider for review, confirm the provider signed off on the document as expected.
- Encounter: If the document type you are auditing is part of an encounter, confirm the document was matched to the correct encounter in the system.
- Order: If the document type you are auditing is part of an order, confirm the document was matched to the correct order in the system.
After entering your audit data in each of the fields listed above, the final column (titled “accurate”) will automatically populate with a “yes” or “no” response. This indicates whether or not the record is error-free.
Step 5: View Your Results
Once your audit is complete, you can use the “Audit Report” tab to view and analyze your results.
Our patient chart audit form will use the data you entered to automatically calculate your audit statistics. This includes the number of documents audited, overall error rate, number of documents with errors, and the total number of errors.
Additionally, the template will calculate error rate percentages by each type of error. Using this data, you’ll be able to easily identify the most common errors in your medical records.
Need Audit Assistance?
Our patient chart audit form was designed to simplify the process of conducting your own internal audit. But if you need additional assistance, our team of experts is here to help. Just schedule a free, 30-minute patient chart assessment. During this call, we’ll offer:
- An overview of how to conduct an audit using your own electronic medical record.
- A customized assessment of potential problem areas.
- Improvement ideas based on your specific pain points.