Risk Management



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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