A chart audit is an assessment of medicinal documentations, to establish what is done, and observes if it can be enhanced. There are innumerable numbers of routine constituents that can be considered in a chart audit. Instances comprise adherence to clinical procedures, patient devotion to medication routines, and provider conformity with coding and records prerequisites. A Chart audits can as well engage a re-examination of the occurrence of symptoms and illness. Evidently, one can perform a chart audit on practically any feature of medicine and medical care. The significant point is that the information one is re-examining should be precise and must be obtainable in the chart. It is as well significant to note down that a chart audit will engage reviewing information that could be considered classified; consequently, it is essential to check with the right institutional guidelines proceeding reviewing charts.
It is therefore necessary to quality control the chart audits for the aforementioned importance of the documents and in order for one to run a successful health care facility. However, before one quality controls the chart audits it is imperative to create a clear working and efficient chart audit. This requires careful planning. A well-planned scheme is necessary to executing a chart audit that will give way to useable information. The initial enquiries to deem are: What is the theme and hub of the audit? For example, breast cancer. Is the theme or focus too constricted or broad? For example, periodical self-breast exam vs. breast cancer in general. Is there an evaluation for the theme or focus? This includes self-reported rate of conducting self-breast exam. Is this evaluation obtainable in the medical record? That is, has the physician in Review of Systems documented it? Has this been calculated previously? If the answer is “yes”, then a standard or criterion exists; if it is “no”, then a criterion for contrast may not subsist. It is also always an excellent thought to notify the medical records assistant when one is performing a chart audit. The records manager can assist in locating the suitable charts, organize a principle time to review charts, and can help with subjects related to confidentiality.
In conducting a chart audit, there are eight steps that re to be followed, they include choosing a topic, recognizing measures, recognizing patient populace, determining sample size, crafting audit tools, assembling information, summarizing results and analyzing and applying the results. These are the basic steps recognized everywhere.
However, due to the fact, this is quite a novice institution; additional measures could be put forward to ensure more quality in the chart audits. These measures include a quarterly review of all the chart audits available and possible follow-ups. A chart review is taking a sample of charts and ledgers to recognize errors and measure the eminence of one’s chart records. When deeming a chart review, the practice must make a decision on the motive, scope, and depth of a chart review (Kaprielian, 2009). Chart Review Options include Onsite vs. Offsite, Retrospective vs. Prospective, and Formal vs. Informal.
On part of updating oneself, as a recommendation it is better for one to associate with establishments like Worldwide association of IS professionals which is devoted to the audit, control, and security of information systems, The Association of Health Care Auditors and Educators and American Association of Professional Coders.
Kaprielian, V., (2009) Chart Audits: the how’s and why’s, Ottawa: Ottawa Inc