CLINICAL CHART AUDITS - by Shelly Johnson
Many think of chart audits in the context of making sure the medical record documentation meets the requirements for the codes that are being billed , but just as valuable (if not more), are increasing the standardization of documentation, consistency of data entry, finding training gaps, creation of concrete performance measurements, and assisting with staff reviews and quality improvement activities.
The frequency of a chart audit is decided on by the practice, but it should have a broad sampling of patients that span all providers. Selecting these patients and looking through their visit record to assess that all the information was included depending on various factors can be incredibly tedious. Did the patient have dilation? If so, what drops were used? Is there a time? If not dilated, why? Was the Review of Systems documented? Were allergy and medications evaluated on that visit? Reviewing individual patient across all locations, providers, age groups, and primary diagnosis can take days, even with a small sample.
The solution? A Destinations Consulting custom report. Although a complex report, it can easily be run for all patients within a given time period and quickly show missing chart documentation based on defined data points that are specific to your practice:
Our client, Dannielle D. claims this report is a life-saver, “The EHR Verification Report that you created for us has enabled me to perform quality assurance checks for every student on a mobile visit in a fraction of the time. We are processing over 15,400 exams per year, and with current funding cuts, we have to be as efficient as possible. In response, we have become paperless to reduce staff tasks related to handling paper, printing, matching and filing, plus required storage space. Now, the Technician takes about 1/3 the time to complete and reconcile their visit and I am able to perform my quality assurance verification in less than 1 minute per visit, whereas before it required 15-45 minutes per visit depending on the volume. This was an essential step in enabling the program to become paperless for the coming school year and saving hundreds of hours annually of staff resources dedicated to these tasks. Thank you so much for creating this valuable resource.”
If this sounds familiar and you could use an extra day or two a month to spend on other tasks, contact Shelly at Shelly@DestinationsConsulting.com for more information.