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 5: Create Audit Tools

To complete your chart audit, you will need instruments on which to record your findings. How they are structured and the details they include will impact upon the analysis you can do, and the eventual usability of your findings.

There are many ways to document findings. It can be done on paper or electronically. Since charts are being reviewed independently, data should be collected in a format that keeps all individual data separate but allows for easy compiling.

A spreadsheet format is ideal for electronic record keeping. Many chart audits will involve the calculation of a rate, percentage, mean, or other statistical measurement. A spreadsheet format will allow for calculating many different measurements.

For those more comfortable with paper-based systems, a sheet of paper pre-printed with key points/questions to check in each chart serves well as an audit tool. Another sheet that compiles and summarizes your findings is also helpful.

The buttons below give examples of 3 common types of audit materials:

  • audit guidelines or instructions
  • audit tool
  • summary form


Examples
Click on one of the images to view the example


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