Patient Record Audits, otherwise known as Medical Record Audits or chart audits are important and common in the healthcare field.

To examine medical records to determine what has been done, and to see if improvements can be made.

Common Reasons for Audits:
  1. Required Measurements - to see if the office and/or hospital meets the required performance measures, usually the Health Plan Employer Data and Information Set (HEDIS)
  2. Administrative requirements - Federal regulations require offices and/or hospitals to justify and document codes and charges
  3. Research
  4. Quality of Care - to measure the quality of care and look for improvements
  5. HIPAA - to see if the rules and standards of HIPAA are being met, especially that charts are being seen, opened and filed by the correct individuals

Planning Audits:
Audits need to be well-thought out and planned. A couple things to consider include:
  1. What is the purpose for the audit?
  2. Is the purpose too specific or vague?
  3. Can the purpose be measured?
  4. Can the measure be found in a medical record?
  5. Has the purpose been measured before?

Audits typically involve 25-30 medical records being pulled, but can also include a single record due to the purpose of the audit. Audits are important and can be used by every aspect of healthcare - finance, IT, research, doctors and staff.

Patient Safety - Quality Improvement
Medical Record Audit - STFM