This document encompasses the process for conducting clinical and chart audits of Medical, Behavioral Health, and Physical Therapy charts. Consistent, current, and complete documentation in the medical record is an essential component of quality patient care. Patient care notes should be precise, methodical, and timely. The patient’s health record is a critical communication tool for exchanging important information with all members of the interdisciplinary team. The health record also serves as a legal document that must be able to withstand judgment in court. Complete and accurate notation is essential for accurate billing and data collection. A chart audit process is implemented to ensure that documentation is appropriate. In addition, the evaluation and improvement of quality of care are critical to the delivery of quality patient care. A clinical audit is part of a continuous quality improvement process. With the consent of the patient, clinical supervision may take place in order to facilitate a clinical audit.
2 Scope and Responsibilities
A chart audit is a review of provider documentation for a single patient encounter. A list of items, by visit type, is identified in the transcription as being present or absent (or not applicable). A clinical audit is a review of provider performance for a single patient encounter. Neither a chart nor a clinical audit is a comprehensive review of care. An analysis of the medical decision-making is out of scope and is part of a chart review process. Billing and coding audits are separate processes and not included in the quality control audit processes. Quality control audits are performed by clinical leadership on all medical and therapy providers. Audits are performed for all new providers within 30 days of beginning work with Override and continue to be conducted, at minimum, bi-annually for each provider.
3.1 A Medical and Behavioral Health Chart Audit consists of 1 new patient chart and 1 follow-up patient chart.
3.2 A Physical Therapy Chart Audit consists of 1 evaluation form and 1 progress form.
3.3 Audits will be performed by clinical leadership, Medical Director and/or designee.
3.4 Charts will be selected at random, and at the discretion of the director, at the end of each month.
3.5 Each chart audit is for one encounter only.
3.6 Providers will receive feedback regarding their compliance/completeness, and related metrics, within 1 week of the audit.
3.7 Providers who score less than 85% will require a second audit in 60 days.
3.8 Any provider not meeting 85% completeness after two audits will be placed on a performance improvement plan.
Last Updated: September 2, 2022