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
Step 2: Identify Measures

Once you’re set on a topic, you need to define exactly what you will measure. Criteria must be outlined precisely, with specific guidelines as to what should be counted as a “yes” (criteria met), and what should be counted as a “no” (not met).

For example, if you decided to review the rate at which foot exams were performed on diabetics in the last year, you would need to decide what qualifies as an adequate foot exam.

  • Is it monofilament testing for protective sensation?
  • Visual inspection?
  • Palpation of pulses?

Many would say all 3 are necessary for a complete foot exam. If only 2 of the 3 have been done, how will you count that?

It may be worthwhile to do a literature review to help in defining measures--ones that have been used successfully in the past will have fewer “bugs” to deal with as you go. HEDIS measures, for example, are defined in exquisite detail (probably more than you would be able to follow in a manual audit). Literature may also help you identify benchmarks for comparison. You may want to learn what benchmarks exist and how other audits were conducted before beginning your own.

If you’re starting from scratch, a pilot audit can be very helpful. Just going through a few records will help to identify potential problems or questions that need to be clarified before starting your full audit.


Examples
Click on one of the images to view the example


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