Patient Chart Audit Guide

Learn how to improve the accuracy of

your medical records

Our Patient Chart Audit Guide is FREE to download!

Simply fill out the form below to get your copy.

What’s in this audit guide?

You’ll learn what steps to take for successful chart audits in healthcare, the typical problems you’ll encounter (and why), along with actionable tips to help you at each stage.

As you work through the steps in this audit guide, we’ll provide you with simple checks and questions to help uncover issues you may not be aware of as you're exploring outpatient chart auditing

Fill out the form below to download.

Patient Chart Audit

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Bonus Offer: Outpatient Chart Auditing Template

Use this free Excel template to record and analyze the results of your patient chart audit. With it you can:

  • Record data: Enter document audit data from your electronic medical record.
  • Track errors: Verify the accuracy of each record using a simple dropdown menu.
  • Generate reports: Automatically calculate the results of your audit, including audit statistics and error rate percentages.
  • Identify problem areas: Uncover the most common types of errors in your EMR.

DISC Corporation: 

The experts in health information management

  • Contracted by hundreds of healthcare organizations across the country
  • 75 years of experience
  • Billions of documents indexed
  • Integrated with every EHR system, including Epic, Cerner, Allscripts, NextGen, eClinicalWorks, and Greenway

5 problem areas of chart management workflow processes

1. Daily chart indexing and filing

Problems you’ll encounter

The most common issue plaguing daily chart indexing is document misfiles. Whether these documents are filed to the wrong patient, document type, or even sent to the wrong provider, accuracy is usually the culprit. Inconsistent filing procedures between staff or clinics can also cause problems.

Beyond that, the time it takes from document receipt to accessibility in the EHR is worth investigating. Talk to your providers. Ask for their feedback. If documents are misfiled—or even not filed at all—they’ll let you know.

Why 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. That 1% difference can lead to big problems for your organization.

Tips for auditing your daily filing

  • Perform a simple audit. Search a random sample of at least ten patients to check the accuracy of their records. Pay attention to the document type, service date, and other indexing information.
  • Review your filing rules. Make sure they’re thoroughly documented and recently updated. You’ll also want to verify that the rules are consistent for every clinic location.
  • If you haven’t already, establish a policy for acceptable time limits on filing.

2. Open orders

Problems you’ll encounter

It’s common for a large organization’s open referral and lab orders to number hundreds of thousands. It’s daunting, to say the least. And the closing process 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 increases, including missed or incorrect diagnoses. Resulting delays can also frustrate patients, causing a drop in your HCAHPS scores.

Why these problems occur

Some contributing factors are uncontrollable, like when a referral patient never books an appointment. But the primary culprit is poor communication.

Referring physicians often send patient data that sits in a filing queue long after the appointment. Similarly, there may be lengthy delays before the primary care provider sees the notes and treatment recommendations from the specialist.

Tips for auditing your open orders

  • Gauge the size of your problem. Run an EHR report to show how many open referral and lab orders your organization has. It might be more than you expect.
  • Talk to your team. Ask administrators for feedback, and learn their perspectives and insights.
  • Determine hours needed to fix the problem. Time how long it takes to close an order. Then multiply that by the number of open orders you have. You should also take note of how many clicks the process takes. Each click consumes a measurable amount of time. Fewer clicks mean faster workflows.

3. Duplicate documents

Problems you’ll encounter

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.

Why these problems occur

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.

Tips for auditing your duplicate documents

  • Ask your providers and administrators a direct question: “Do you see duplicate documents? If the answer is yes, dig deeper. Ask probing questions to find out when and where they see them most often. Find the patterns to discover the source(s).
  • Once you uncover a root cause, establish a policy to address it. Standardize your procedures for handling duplicate documents.

4. Paper workflows

Problems you’ll encounter

Paper workflows are resource-intensive. Each step of the process may not seem like much on its own. But collectively, manual indexing consumes a substantial amount of your team’s time and energy. Scanning, coding, indexing, tasking—it all adds up.

That’s why it’s so easy for backlogs to form. Your team can’t keep up when forced to work so slowly. And the longer your filing takes, the less likely the patient data is available when it’s needed.

Why these problems occur

Even with an EHR, many organizations still rely on paper documents. When a new form comes in, the information is manually entered into the EHR by an administrator. It’s a slow, error-prone process that hinders your team and places patients at risk.

Tips for auditing your paper workflows

  • Spend some time at different clinics and watch the workflows in action. Then ask some questions. Are the same forms always used? How and when does the information get entered? Is the document simply scanned in, or is discrete information updated in the system? How quickly does this occur? Are digital forms an option?
  • Determine the size of your issue. Take the number of paper documents each patient fills out during their visit and multiply that by the number of visits each day. That's how long it would take you to fix the problem.

5. Legacy information

Problems you’ll encounter

Storing legacy information can 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 is risky as well. Patient information housed outside of your current EHR (including scanned paper charts) could pose security and accessibility concerns.

Why these problems occur

Legacy data is often retained for legal obligations. Retention periods vary by state, but many organizations hold on to documents longer than they need to. Other times, an organization might be working toward a digital transformation or transitioning through a business acquisition.

Tips for auditing your paper workflows

  • Update your retention and destruction policy. Make sure your organization isn’t holding on to documents unnecessarily.
  • Review how the legacy information is being used. If your organization is storing legacy information in either paper or electronic form, when and how is it accessed? How could that process be improved?