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

Purpose:
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.

Sources:
Patient Safety - Quality Improvement
Medical Record Audit - STFM