Many are familiar with the term audit as a complex review of tax documents that searches for any errors or mistakes. The idea of chart audit has similarities to this, but also differences. In medicine, doctors, hospital facilities and others may routinely conduct chart audits, certainly to look at ways things could be improved in medical care delivery, but also to gain knowledge about the population they serve and about human disease.
When properly kept, medical charts, especially when taken as a group, can contain incredible amounts of information. Such information could be used to determine if there are health problems that are being routinely missed or if there is a relationship between things like age and certain health issues. Looking at charts, whether online or paper, can also be revealing about how well a medical facility records and faithfully keeps track of information. Missing information such as labs, allergy to drugs, or other vital things might suggest quality of care could be improved with better record keeping skills.
Often, a chart audit is conducted to improve quality and it’s limited to looking for certain things. A busy family practice office might want to assess the care it’s giving to its pediatric patients and particularly whether it is making sure all children receive immunizations on schedule. The practice could evaluate only pediatric charts and look at birth date as compared to vaccination information, to determine whether they are meeting best practices.
Should the chart audit conclude that not enough attention is being paid to this matter, there could be many ways to handle that information. The practice could begin a program of family education. They might even decide that since they have failed to give immunizations they should contact all families who have kids overdue for vaccines and inform them. Both these steps could be employed so that greater quality of care would be implemented as a result.
Other examples of the chart audit can take into account how well a facility meets the special needs of certain populations like the elderly. A hospital could conduct a chart to determine how frequently there are injuries among elderly patients in the hospital. High numbers might suggest greater vigilance, hiring more staff, or training staff to a greater level. Hospitals could look for other information additionally, such as the rate of patient infection after surgery, or the number of people who make return trips to the emergency room in two to three days. These numbers provide facilities with hard data on whether they are giving adequate and appropriate medical care.
Insurance companies may request chart audit data routinely to verify if they have been appropriately billed for any treatment of their clients. These reviews can take time too, and are often of more frustration than benefit to physicians. Certain government systems in association with either government health or credentialing of hospitals also demand chart audits from time to time, that may focus on a variety of factors. Individuals, who maintain their own medical charts at home, may periodically request the auditing of any new records, to make sure that charting remains accurate.