Auditing medical records can be a time-consuming process, but the benefits far outweigh the inconvenience.
In the simplest terms, a medical records audit is a chart review which is used to identify what is being done correctly and what is in need of improvement. Depending on the objective, medical record audits can be performed either by an external agency or by staff within an organization. Audits conducted by a third party are generally to review compliance, and internal audits are usually performed to evaluate current treatment processes and measure quality of care. This post will cover the latter.
Below is an eight-step guide on auditing medical records which nurses can use to ensure their facility is providing the best patient experience.
Step 1: Choose the Focus of Your Audit
In general, the purpose of your audit should be to identify the clinical practices that are inconsistent or in need of improvement. The audit objective should have the following characteristics:
- Measurable based on the data available in the records
- Important to the efficacy of your hospital and the care of your patients
It’s also a good idea to choose a topic in which you are personally interested. You’ll likely be able to recognize subtleties in the data which might otherwise have gone unnoticed.
Step 2: Define Measurement Criteria
After you’ve identified the focus of your medical records audit, determine the specific measurement criteria for the review. Then, conclude which factors will decide whether or not these criteria are met.
Performing a literature review can help expedite the process, since using methods already proven to be successful eliminates the need to develop your own standards for measurement. Literature reviews can also provide benchmarks for comparison.
Step 3: Determine Which Records to Review
In order to choose which records to include the audit, you must identify the precise patient population to be evaluated. Consider age, gender, clinical status and treatment regimen, and be sure everyone involved in the audit knows exactly what determines whether a patient is included or excluded.
Often the focus of the audit and the measurement criteria will guide this decision.
Step 4: Decide Sample Size
Completing an audit of every chart which meets your inclusion criteria is usually not feasible, so a good rule of thumb is to choose approximately 10 percent of the eligible charts to review.
Statistical significance is heavily impacted by the sample size—if not enough records are audited, the variables will be too numerous and the audit results will have limited application.
Step 5: Develop Recordkeeping Tools
How you plan to collect and analyze the results of the audit will dictate the type of recordkeeping tools you create—for example, will you record data electronically or with a paper-based system? The important thing is to organize the results in such a way that allows for evaluating individual records as well as aggregate data.
Be deliberate about which data is recorded—this affects the types of analyses you can perform and the future usability of your discoveries.
Step 6: Gather Data
Coordinate the details of the audit: date and time to be performed, the number of charts to be pulled, the individuals involved, etc. Enlist the assistance of the medical records manager to help procure the charts and ensure HIPAA compliance. Then, perform the audit and collect the data.
Step 7: Summarize Your Findings
This step is crucial since disorganized or irrelevant data can result in an inability to use the audit results to enact change. Reflect on how the findings will be used and summarize the data in the way which will be most impactful.
Step 8: Analyze the Data and Implement Appropriate Changes
Review the findings of the audit and identify the opportunities for improvement. For example, if you see certain patient comfort solutions—such as applying a topical anesthetic before minor procedures—being used inconsistently, you can add them to the standard protocol. You can also take advantage of existing benchmarks to help guide your decisions.
Auditing medical records may seem tedious, but the data contained within these charts can be extremely valuable for improving hospital efficiency and ensuring patient satisfaction. It’s important to use all of the resources at your disposal to provide the best possible experience for your patients.
Looking for even more ways to improve patient satisfaction? Download our free guide, The Ultimate Patient Satisfaction Checklist for Nurse Managers.