Risk Management
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Medical Record Audit Form
Medical Record Audit
Select 10 active patient charts with at least 3-5 prior visits: the most recent visit should have taken place within the past 6-12 months. If information should be present and is not, place an 0 in the box for that chart. If information is present, rate the quality of the information with 3 = Superior, 2 = Satisfactory, and 1 = Unacceptable. Use “NA” to score items that do not apply to a given chart (e.g., patient has no allergies).
Chart number |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Pages have patient ID | ||||||||||
| Contains biographical and/or personal data | ||||||||||
| Person providing care identified on each chart entry | ||||||||||
| Entries are dated | ||||||||||
| Entries are legible | ||||||||||
| Problem list is complete | ||||||||||
| Allergies and adverse drug reactions are prominent | ||||||||||
| Absence of allergies and reactions prominent | ||||||||||
| Appropriate past medical HX | ||||||||||
| Smoking, alcohol, or substance abuse HX documented | ||||||||||
| Pertinent HX and physical | ||||||||||
| Lab and other tests ordered as appropriate | ||||||||||
| Working diagnoses are consistent with findings | ||||||||||
| Plans of action/treatment are consistent with diagnosis(es) | ||||||||||
| Problems from previous visits addressed | ||||||||||
| Evidence of appropriate use of consultants | ||||||||||
| Evidence of continuity and coordination of care between primary and specialty physicians | ||||||||||
| Consultant summaries, lab, and imaging study results reflect primary care physician review | ||||||||||
| Completed immunization record | ||||||||||
| Prescriptions and refills noted | ||||||||||
| Med sheet used and appropriately located | ||||||||||
| Chronology maintained | ||||||||||
| Informed consent noted for all procedures and appropriate prescriptions | ||||||||||
| Patients are adequately informed (i.e., there is documentation of patient education, follow-up instructions) | ||||||||||
| Missed/canceled appointments | ||||||||||
Chart number |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
| Follow-up on missed/canceled appointments | ||||||||||
| Telephone calls regarding patient care noted | ||||||||||
| Charts are organized in a consistent manner internally | ||||||||||
| Transcription, if used, is accurate and physician review is noted | ||||||||||
| There is a consistent, organized format for notes (i.e., is SOAP or similar format used?) | ||||||||||
| Chart contents are securely fastened to the jacket | ||||||||||
| No inappropriate information is in the chart (e.g., subjective or personal remarks about patient, family, or other caregivers) | ||||||||||
| No inappropriate alterations or omissions (e.g., erasures, missing pages) |
Credits: The Medical Record Audit form was provided by the American Medical Association/Specialty Society Medical Liability Project.
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