Outlined above are those items cited in mock surveys from our consulting team. The consultant team encourages all organizations to conduct ongoing medical record audits at the point of care, based on the following indicators: presence, timeliness, legibility (whether handwritten or printed), accuracy, authentication, and completeness of data and information. This is what the regulatory agencies are looking for when they are surveying. By doing so, this documentation ensures that the care provided to your patients is based on the assessment of the individual patient and their plan of care, is in line with the physician’s orders and treatment provided, follows the organization’s policies, procedures, and bylaws and meets the regulatory agencies requirements that ensure safe quality patient care.
So, please take this list of medical record audit items and get started today!
References
- What is the Importance of a Medical Record Review? Why Do Healthcare-Related Lawsuits Need Them? by Rajeev Rajagopal, Jan 17, 2024, Medical Record Review.
- Survey Activity Guide, TJC 2024
- TJC Comprehensive Accreditation Manual for Hospitals 2024
- CMS SOM April 2024
For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
