Chart audit tool example

The advantage of performance audits using data from EHRs is that you can often pull data on the entire population of patients seen during the specified time period, rather than limiting the audit to a subset of 10 to 30 patient records. Provide the IT staff, or whoever will pull the data, precise written descriptions of the criteria for inclusion and exclusion. A sample of instructions for IT for a performance audit data pull are provided in Module 8 Appendix C.

Unlike with electronic data, where you should be able to collect data on the universe of patients in your target population, you will have to sample patients when doing audits using paper records. Smaller samples are too vulnerable to random variability. Another approach can be to sample 10 percent of eligible charts or to take a convenience sample from a single day of patients who meet inclusion criteria.

For monthly performance monitoring, an audit of the records of 10 patients seen during that month can be sufficient for a practice to evaluate progress toward an improvement goal. You will need to obtain a list of patient records that you want to review. The patient record numbers then need to be given to medical records staff, who can pull the charts and provide them to you for audit. You will need to work closely with the QI team and practice manager to ensure that you do not create an undue burden on medical records staff and that you do not pull and retain charts of patients being seen that day whose medical records will be needed.

All data collected from a practice are highly sensitive. Whether the data are from patient records or staff surveys, the practice facilitator must keep data secure at all times. A number of measures can be taken to protect confidential information. As a rule, never take identified patient data offsite from a practice.

Electronic data are particularly difficult to secure, especially in the era of cloud computing. Any data transmitted to or stored on your computer, tablet, or laptop should be deidentified with all personal health information PHI removed.

A key code connecting patient PHI, including medical record number, to data you maintain on your computer or any that you are transporting offsite will need to be created to allow you to reidentify data if needed. This key code should be housed at the practice and never taken offsite. In addition, you will need to set the security on your laptop to require a password to access any practice information stored on it. Any data transmitted through email or stored on cloud applications should similarly be deidentified, with the master code maintained only at the practice.

You will need to be familiar with and make sure you comply with all regulations of the Health Insurance Portability and Accountability Act as it relates to performance data and access to patient data. Assessing clinical performance can be a threatening and sensitive process for a practice. You will also need to clarify the conditions under which this is acceptable to the practice. Kaprielian, MD. Fam Pract Manag. For many family physicians, the idea of a chart audit conjures up images of federal investigators or insurance company representatives descending on their offices to look for evidence of wrongdoing.

For the most part, however, a chart audit is not so scary. A chart audit is simply a tool physicians can use to check their own performance, determine how they're doing and identify areas where they might improve. The purpose of this article is to describe some scenarios in which a chart audit might be helpful and to offer step-by-step instructions for doing one.

Chart audits can serve many purposes, from compliance to research to administrative to clinical. You can conduct a chart audit on virtually any aspect of care that is ordinarily documented in the medical record. Practices frustrated with clinical processes that don't work well can use chart audits to document that something is wrong, find the defect in the process and fix it.

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.

For example, a practice might review charts to see how often a particular vaccine is offered, given or declined.

If the audit determines that the vaccine is not being offered or given as recommended, then there is room for improvement. The same practice could review the panels of individual physicians within the group to see if they differ in performance on this measure and to give focus to their improvement efforts for additional chart audit ideas , see below.

Percentage of women ages 21—64 who have had a Pap smear within the past three years. Percentage of elderly adults with documented fall risk assessment within the past year. Percentage of patients with diabetes with an A1C level recorded in the last year. Percentage of patients with diabetes with a documented eye exam within the last year. Percentage of patients with persistent asthma who are on an anti-inflammatory agent. A chart audit is one of numerous data sources available for quality improvement efforts.

Below we describe eight steps to a formal chart audit. Although the process is not necessarily linear, we will discuss each step in the order it might typically occur, using the example of a breast cancer screening audit to illustrate each step.

Because the audit will involve reviewing confidential data, it is important to check your institutional guidelines regarding patient confidentiality before you get too far into the planning process.

Step 1: Select a topic. The focus of your audit must be clear, neither too narrow nor too broad, and measurable using data available in the medical record.

If possible, choose an area that interests you. You will find that you are more able to recognize nuances in your study when you have personal interest in the topic. Of course, your topic should also be of interest to the practice, perhaps a problem or aspect of care that the providers have identified as needing improvement. The Joint Commission recommends studying issues that are high frequency, high risk or both.

You should also consider early in the process how important external comparison is to your purpose. If it is quite important, then choose a topic that has an existing, well-defined measure and available benchmark data — even one you might not choose otherwise — because this will be more practical than developing your own standard for comparison.

Chart auditing is an iterative process — don't be discouraged if you change directions several times before settling on a topic. Example : Your practice wants to measure how well it's doing on meeting recommendations for preventive care. Since the insurance carriers in the area are focusing heavily on women's health, the group decides to focus its chart review on screening for breast cancer mammography.

Step 2: Identify measures. Once you're set on a topic, you need to define exactly what you will measure. For example, if you decided to review the rate at which foot exams were performed on patients with diabetes in the last year, you would need to decide what qualifies as an adequate foot exam.

Is it monofilament testing for sensation? Visual inspection? Palpation of pulses? Many would say all three are necessary for a complete foot exam. If only two of the three are documented, how will you count that? It may be worthwhile to do a literature review to help you define your measures or consult measures used by insurers or accrediting bodies; adopting measures that have been used successfully in the past will make your work easier. A literature review may also help you identify benchmarks for comparison.

Once you've chosen measures that seem workable, it can be helpful to conduct a pilot audit. Just going through a few charts will help to identify issues that need to be clarified before starting a full audit. Example : For your audit on breast cancer screening, the group considers several measures, including the following:.

Time since last mammogram. This provides the most specific information but would require more analysis. Mammogram completed within last year. This measure attempts to assess compliance with clinical guidelines.

The U. Preventive Services Task Force recommends screening mammography every one to two years for women age 40 and older. Mammogram ordered within last year. Do you want to measure only whether the study was done, or whether it was recommended or ordered by the provider? Should providers be held accountable when patients decline to have the test? After considerable discussion, the group decides to measure whether a mammogram was completed or recommended within the last 24 months.

Step 3: Identify the patient population. To determine which records to review, you need to define the population you want to assess. Characteristics to consider may include age, gender, disease status and treatment status. In many cases, the focus of the audit and even the measure itself will help to define the population.

You'll also need to develop specific inclusion or exclusion criteria. Example : In keeping with the HEDIS breast cancer screening measure that your group decided to follow, your patient population will be women age 40 to Because you'll be looking for evidence of a mammogram in the past 24 months, the lower age limit for the sample will be Only those patients with at least three visits in the last two years and one in the last 13 months will be included. You decide to exclude women who have had bilateral mastectomies or are terminally ill.

Step 4: Determine sample size. A manual audit of all charts meeting your inclusion criteria will not be feasible in most situations. Here are a few sample chart audit forms you can freely use as references. It is available in all versions of PDF for you to have a convenient viewing and editing. Every business would strive to get its operations to improve and have fewer errors.

Audit charts are one of the tools a company uses to achieve quality improvement. So, how does it help companies in improving? How does a chart audit works? Here are a few benefits and purposes of a chart audit in a company. Quality Improvement: Chart audits are known tools for quality improvement in companies. It helps out in identifying errors in processes and procedures in company operations.

Record Documentation: This document can record the performance of an operation or procedure. You can use the chart audit as a medical record for the patient.

It helps you track if the patient has gone through all the tests they need to have. Some chart audits that are used for medical records already have corresponding fees of the tests run for the patient. Audit charts make it easier to track all the procedures that need charges. These mentioned advantages are only part of how useful chart audits are. It has more benefits than you can imagine.

The overall purpose of a chart audit is to track mistakes in a process to take action for solutions. Creating chart audits might sound technical and challenging, but it will be easier if you understand its purposes and uses.

Chart audits are the usual tools for quality control. Quality improvement is essential for a business since it deals with the performance of their operations. That is why making this document needs thorough planning and preparing.