medical records chart analysis

By DISC Corporation | January 3, 2023

As a healthcare provider, your electronic health record (EHR) plays a vital role in delivering high-quality patient care. But these critical systems can be plagued with errors and inefficiencies that cost you time and money – or worse, impact patient health, safety or satisfaction. That’s why it’s important to make regular medical records chart analysis part of your ongoing health information management (HIM) duties.

Why Should I Conduct A Medical Records Chart Analysis?

Regularly auditing your medical records is a great way to not only catch errors, but to identify entire HIM processes that need improvement. The audit process itself is simple enough to conduct on your own using our free Patient Chart Audit Guide, and can help ensure your medical records are both accurate and compliant. To learn more about the benefits, check out our recent blog post: 5 Reasons To Conduct A Medical Record Chart Audit.

In this post, we’ll take a closer look at the most common issues you may uncover during your audit.

Top 5 Problems You’ll Uncover During A Chart Audit

1. Daily Chart Indexing And Filing Errors

In our experience, the most common issue you’ll find in a medical records chart analysis is related to daily chart indexing and document misfiles. When taking a closer look at your EHR, expect to uncover a variety of errors and inaccuracies. This can include faxed or scanned documents being filed to the wrong patient, document type, or even sent to the wrong provider. Inconsistent filing procedures between staff or clinics can also cause problems.

Why do these problems occur? When filing processes rely on manual data entry, mistakes are bound to happen. Hand-keyed data is often less than 99% accurate. So that 1% difference can lead to big problems for your organization – especially when you consider that a 200-provider organization requires about 40 million clicks per year when entering faxes and scanned documents.

Additionally, patient documents may be filed differently depending on the preferences of an individual provider or staff member. These variables in your filing workflow can cause inconsistencies in the medical record.

2. Open Orders

For a large healthcare organization, open referral and lab orders can number in the hundreds of thousands. It’s daunting, to say the least. And closing the loop on orders can be slow and tedious, especially while fulfilling tracking and reporting obligations.

Open orders leave informational gaps that increase patient risk – and the likelihood of medical error. This can lead to missed or incorrect diagnoses, or cause a patient to have tests repeated unnecessarily.

3. Duplicate Documents

Duplicate documents create more work for everyone on your team. Providers have more documentation to sift through. Your HIM team has a longer queue of unindexed files. And your IT department has more data to manage. Duplicates are a drain on your organizational processes.

Inefficient processes – both internal and external – cause documents to get reproduced and repeatedly indexed. With so many other responsibilities, your team likely struggles to catch them when they occur. Over time, this creates a serious and growing issue.

4. Paper Workflows

Even with an EHR, many organizations still rely on paper documents. And if you’re using paper workflows, you know how time- and resource-intensive they can be. Each step of a paper-driven process may not seem like much on its own. But collectively, manual indexing can consume a substantial amount of your team’s time and energy.

Scanning, indexing, tasking – it all adds up. And this slow, error-prone process also takes your staff away from providing direct patient care.

5. Legacy Information

During a medical records chart analysis, it’s not uncommon to find filing cabinets packed with outdated documents. Storing this legacy information is not just inconvenient. It can also be risky, costly, and completely unnecessary.

Storing paper charts in-house takes up valuable clinic space. And storing them off-site is costly – not to mention time-consuming when you need to retrieve a document. It also raises security and accessibility concerns.

Electronic data storage isn’t risk-free, either. Patient information housed outside of your current EHR (including scanned paper charts) could pose security and accessibility concerns.

Ask around the office, and you’ll likely hear that legacy data is being retained for legal reasons. But while retention periods vary by state, many organizations hold on to documents longer than they need to. This begs the question: When was the last time you reviewed your document retention and destruction policy?

Taking a closer look at your medical records can confirm whether or not your organization is holding on to documents unnecessarily. And reviewing how this legacy information is being used can help you identify future process improvements.

Start Your Medical Records Chart Analysis Today

If you’re interested in conducting your own patient chart audit, start by downloading our free Patient Chart Audit Guide. This valuable resource offers step-by-step instructions on how to conduct your own internal audit. You’ll learn what steps to take in a successful audit, along with actionable tips to help you at each stage. We even include an outpatient chart auditing tracker – making it easy to record audit data and analyze your results.

If you need assistance performing your audit, schedule a free 30-minute patient chart assessment with our team of experts.


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