Overview
What is a Chart Audit?
Purposes of the Chart Audits
Chart Audits in Quality Improvement
Planning a Chart Audit
Questions to Consider
How to Conduct an Audit
Check Your Understanding
Using Results for Quality Improvement
Summary

Purposes of the Chart Audits

There are many reasons one might want or need to do a chart audit. Other examples include:

  1. Required measurements
    The Health plan Employer Data and Information Set (HEDIS) is the most widely used set of performance measures in the managed care industry. Health plans are required to report this large set of measures annually. Employers and prospective members can then compare plans on their quality of care. Chart audits are often part of the data collection methods for these measures. [HEDIS will be discussed in more detail later in the module, or see http://www.ncqa.org/index.htm]

  2. Administrative requirements
    Federal regulations require medical records documentation to justify charges coded and billed for. Audits are often used to measure compliance.

  3. Research
    Medical records contain a wealth of data that may be useful in research, from measuring the prevalence of symptoms/diseases to comparing the impact of various treatment strategies. Research applications of audits can be clinical (such as reviewing the prevalence of blindness in diabetic and non-diabetic patients) or operational (such as reviewing the hospital length of stay for surgeries performed on Monday vs. Friday).

  4. QI
    Perhaps the most desirable reason for chart audits is to measure quality of care in order to improve it. Health professionals, frustrated with processes that don’t work as they should, can use audits to document that something is wrong, find the defect in the process, and fix it. Practices and health systems that agree upon guidelines and processes of care can use audits to assess how well they are following them.

You can conduct a chart audit on virtually any aspect of healthcare. The important point is that the data you are reviewing should be accurate and must be available in the medical record. It is also important to note that a chart audit will involve reviewing data that may be deemed confidential; therefore, it is important to check the appropriate institutional guidelines before reviewing charts.

 

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