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Medical Record Audits

Virtual Medical Record Review
Are you prepared for virtual medical record review? Regulators and accreditors are conducting many medical record reviews virtually during the Covid-19 Pandemic. To be successful, test out your system for ease of viewing, connectivity, and viewing critical portions to assure compliance.

What does your Medical Record Audit look like?
Organizations routinely conduct concurrent and retrospective audits in a variety of formats using a variety of tools. However, we have found this practice changing with the electronic health records and hybrids of electronic and manual documentation in daily patient care activities.

Medical Record Audits are REQUIRED by Regulators and Accrediting agencies.
Organizations must remain vigilant in these days of virtual review, as large data, automated data reporting systems and canned data reports may not audit all necessary documentation or identify potential compliance issues. The best medical record audits provide an ongoing review of medical records 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.

Who Should Be Involved?
Risk Management, Case Management, Quality/Performance Improvement, Finance and Clinical Departments should all be participating in medical record audits. Medical Record Audits not only provide identification of the above-mentioned indicators, but also provide different perspectives regarding needed documentation and identification of ‘triggers’ such as potential adverse events that may have occurred or care denials.

Encourage Collaborative Reviews
Organizations that encourage a standardized medical record audit tool can benefit when it comes to data correlation, data analysis and data reporting – as multiple areas will be reviewing similar record components. Key features of a medical record audit tool include patient assessment and care timelines, medication administration practices, discharge planning practices, surgical care, and other clinical support activities like rehabilitation, dietary, speech therapy, respiratory therapy, and physician consultations. If your organization is not currently engaged in both concurrent medical record audits (EMTALA, Surgical Care, Pain Management) and retrospective medical record audits (Case Management, Discharge Plan, Physician Referrals) you may be at risk of not meeting regulatory and accrediting patient care expectations. Develop a standardized medical record audit tool and include department staff, such as Risk Management and Leadership, in addition to clinical providers and staff to assure a comprehensive record audit process whether done in person or virtually.

James Ballard

Author James Ballard

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