A medical record audit form is the type of form that is prepared to record the data and the information after the auditor completes the medical record audit. It is the formal form document that contains all the information about the audit process conducted by the auditor. These form templates that are provided below are the samples of the medical record audit form. If you want a better idea or know more about the medical record audit form you can download these forms for free.
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What Do You Understand by Medical Record Audit?
In the simplest term possible, a medical record audit can be termed as the review of the chart of the medical records, to know what is done properly and what needs improvement. It completely depends on the objective and aim of the organization that whether the audit will be done by the external agency or the staff withing will be responsible for performing the audit.
The audit that is performed by an external agency is usually to know about and review compliance. Whereas the audit performed by the internal group is to record and evaluate the current or the ongoing treatment procedures and measure the quality of the care that is provided to the patients.
How Will You Perform a Proper Medical Record Audit?
There are in general 8 steps that you can follow for a successful medical record audit
Step 1: Choosing the Focus of the Audit
The purpose of this audit should be to find out the inconsistency and incompetence in clinical or medical practices or the services that need improvements. Your audit objective should be specific, measurable according to the data that is provided in the medical records and is important to the success of your hospital and the patients.
Step 2: Defining the Measurement Criteria
After you have set the focus and the objective of your audit set the measurement criteria. This will the benchmark based on which you will be able to conclude whether the recorded data meets criteria or not.
Step 3: Determining the Records that are to be Reviewed
To identify which records to incorporate in you have to identify the precise population of the patients who will be evaluated. This will give you the data on what to put in the record and whatnot.
Step 4: Deciding the Sample Size
Including all the charts lot records that fit your criteria are not possible or will be difficult. Therefore it is necessary that you reduce the sample size and then conduct the audit.
Step 5: Developing a Record-Keeping Tool
The method that you will use to record and analyze the records will determine the tool of your record keeping. But the idea behind is to organize the data so the evaluation becomes easier and simpler.
Step 6: Gathering the Data
Now you can start the process of auditing and gather all the necessary data that needs evaluation and then conclude whether it is on par with the set criteria.
Step 7: Summarizing the Findings
This step is a little bit crucial because if the data is disorganized or is irrelevant than it can mess up the audit result. Therefore you have to be really cautious about summarizing and organizing the data.
Step 8: Analyzing the Data and Implementing the Changes
The first thing that you need to do is to review the collected data. This will help you come up with the ideas that you can implement to make changes and improvements where needed.
Why is it Important to Perform Medical Record Audit?
If there is any, problem with the medical records of the patient, it is possible that the patient might get the wrong medication or wrong health service. This may lead to cause harm to the patient. Therefore it becomes imperative that you conduct the medical record audit so as to avoid any unwanted or inconvenient issue. There is a possibility that medical records getting swapped due to some similarities in two patients. Hence an audit will help you to prevent the occurrence of this type of problem. That is why the auditor uses a medical record audit form for proper and correct collection of the data.
The importance of the medical record audit form is huge. It helps in the better organization of data and prevents miss management of the patient information. You are very well aware that you need to focus on and what information you need to put during the audit process when you have the medical record audit form.
That is why for your convenience we have provided some professional forms as for example so that you can download them and b able to prepare the one you want. You can use these templates in two ways. First, you may use them as a reference and create your desired form structure or second, you may use any one of this and edit and customize it as per your choice and get your desired one.
The templates can also give you ideas about some points that you can use when you audit. You can use the categories provided here as an example and use them as categories for your audit as well.