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A chart audit

  • Is a systematic review that…
  • Measures performance and…
  • Improves quality.

A chart audit is an examination of medical records, to determine what is done, and see if it can be done better. There are countless numbers of performance components that can be measured in a chart audit.

A chart audit is one of several tools available for quality improvement.

It is important to note that chart audits are not done to root out bad quality but rather to rate quality.

Purposes of the Chart Audits:

There are many reasons why you need to do a chart audit, but the main are:

  • Required measurements
  • Administrative requirements
  • Research
  • Quality improvement

Perhaps the most beneficial use for a chart audit is to measure quality of care so that you can improve it. Chart audits are often used as part of a quality improvement initiative.

Medical chart audits help to improve productivity, business standards, and the bottom line. These services are competently performed through the coordinated effort of support personnel with abundant knowledge in case management and healthcare.

General steps in chart audit:

  • Select a subject.
  • Establish criteria with standards (involve peers and experts).
  • Identify sampling procedure.
  • Train chart reviewers for consistent, accurate application of criteria and standards.
  • Collect data.
  • Analyze data.
  • Compare findings to criteria and standards.
  • Repeat chart audit following an intervention to identify changes in practice.

Medical chart audits focus on different aspects of a practice such as the sharing of findings and results, compliance, statistical sampling methodologies, coding concepts, regulatory guideline competence and knowledge, quality assurance, abstraction ability, auditing capacity for medical records, and their scope.