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AUDITING MEDICAL RECORDS
PURPOSE:
A. The purpose of quantitative analysis is primarily to identify obvious
and routine omissions that can be easily corrected.
B. The purpose of qualitative analysis is the identification of
correctable deficiencies, patterns of poor documentation practices, and
potentially compensable events.
DEFINITION:
Auditing refers to the quantitative and qualitative analysis of Medical
Records.
A. "Quantitative analysis" is a review of prescribed areas of the
medical record for identifying specific deficiencies in recording.
B. "Qualitative analysis" is a review of the content of medical record
entries for inconsistencies and omissions, which may signify that the
medical record is inaccurate or incomplete.
PROCEDURE:
The following list outlines the steps for auditing Medical Records by
the Medical Records Technician based on quantitative and qualitative
analysis. This procedure makes the medical record more complete for
reference in continuing resident care; for protecting the legal interest
of the resident, physician, and the facility; and meeting regulatory
requirements.
A. A 10% random sample of all Medical Records shall be audited monthly.
B. A Monthly Chart Audit Checklist is maintained for every medical
record. The Checklist is a criteria-based, monitoring tool used to
ensure that a specific standard is always met. A check mark is placed
next to item that meets the standard. A x (in red ink) is placed next to
each item that does not meet the standard.
C. A list of deficiencies that need to be corrected is sent to the
responsible department head within five days of the audit.
D. The date the deficiencies noted, it is to be recorded on the
corresponding resident index card in the "Tickler File."
MEDICAL RECORDS - 35-03-009
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