Why chart audit

A chart audit is one of numerous data sources available for quality improvement efforts. Below we describe eight steps to a formal chart audit. Although the process is not necessarily linear, we will discuss each step in the order it might typically occur, using the example of a breast cancer screening audit to illustrate each step.

Because the audit will involve reviewing confidential data, it is important to check your institutional guidelines regarding patient confidentiality before you get too far into the planning process. Step 1: Select a topic. The focus of your audit must be clear, neither too narrow nor too broad, and measurable using data available in the medical record.

If possible, choose an area that interests you. You will find that you are more able to recognize nuances in your study when you have personal interest in the topic. Of course, your topic should also be of interest to the practice, perhaps a problem or aspect of care that the providers have identified as needing improvement.

The Joint Commission recommends studying issues that are high frequency, high risk or both. You should also consider early in the process how important external comparison is to your purpose. If it is quite important, then choose a topic that has an existing, well-defined measure and available benchmark data — even one you might not choose otherwise — because this will be more practical than developing your own standard for comparison.

Chart auditing is an iterative process — don't be discouraged if you change directions several times before settling on a topic.

Example : Your practice wants to measure how well it's doing on meeting recommendations for preventive care. Since the insurance carriers in the area are focusing heavily on women's health, the group decides to focus its chart review on screening for breast cancer mammography. Step 2: Identify measures. Once you're set on a topic, you need to define exactly what you will measure.

For example, if you decided to review the rate at which foot exams were performed on patients with diabetes in the last year, you would need to decide what qualifies as an adequate foot exam. Is it monofilament testing for sensation?

Visual inspection? Palpation of pulses? Many would say all three are necessary for a complete foot exam. If only two of the three are documented, how will you count that? It may be worthwhile to do a literature review to help you define your measures or consult measures used by insurers or accrediting bodies; adopting measures that have been used successfully in the past will make your work easier.

A literature review may also help you identify benchmarks for comparison. Once you've chosen measures that seem workable, it can be helpful to conduct a pilot audit. Just going through a few charts will help to identify issues that need to be clarified before starting a full audit.

Example : For your audit on breast cancer screening, the group considers several measures, including the following:. Time since last mammogram. This provides the most specific information but would require more analysis. Mammogram completed within last year.

This measure attempts to assess compliance with clinical guidelines. The U. Preventive Services Task Force recommends screening mammography every one to two years for women age 40 and older. Mammogram ordered within last year. Do you want to measure only whether the study was done, or whether it was recommended or ordered by the provider? Should providers be held accountable when patients decline to have the test? After considerable discussion, the group decides to measure whether a mammogram was completed or recommended within the last 24 months.

Step 3: Identify the patient population. To determine which records to review, you need to define the population you want to assess. Characteristics to consider may include age, gender, disease status and treatment status. In many cases, the focus of the audit and even the measure itself will help to define the population. You'll also need to develop specific inclusion or exclusion criteria.

Example : In keeping with the HEDIS breast cancer screening measure that your group decided to follow, your patient population will be women age 40 to Because you'll be looking for evidence of a mammogram in the past 24 months, the lower age limit for the sample will be Only those patients with at least three visits in the last two years and one in the last 13 months will be included.

You decide to exclude women who have had bilateral mastectomies or are terminally ill. Step 4: Determine sample size. A manual audit of all charts meeting your inclusion criteria will not be feasible in most situations. That's where sampling comes in. Consider appointing a Chart Audit Coordinator with the authority to set aside time for record auditing and tap others in the practice for assistance as needed. Some larger practices have found that a team approach to conducting chart audits combined with a rewarding incentive program produces better results and increases staff morale.

This approach gets everyone in the practice involved in the auditing and patient recall process and turns a tedious task into a fun challenge. Renewing contact with patients who have already visited your practice is one of the most cost efficient ways to increase your practice cash flow. So if you have let your auditing program lag during busy times, revitalize your chart audit system today and start enjoying additional profits!

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A sample of instructions for IT for a performance audit data pull are provided in Module 8 Appendix C. Unlike with electronic data, where you should be able to collect data on the universe of patients in your target population, you will have to sample patients when doing audits using paper records. Smaller samples are too vulnerable to random variability. Another approach can be to sample 10 percent of eligible charts or to take a convenience sample from a single day of patients who meet inclusion criteria.

For monthly performance monitoring, an audit of the records of 10 patients seen during that month can be sufficient for a practice to evaluate progress toward an improvement goal. You will need to obtain a list of patient records that you want to review.

The patient record numbers then need to be given to medical records staff, who can pull the charts and provide them to you for audit. You will need to work closely with the QI team and practice manager to ensure that you do not create an undue burden on medical records staff and that you do not pull and retain charts of patients being seen that day whose medical records will be needed.

All data collected from a practice are highly sensitive. Whether the data are from patient records or staff surveys, the practice facilitator must keep data secure at all times. A number of measures can be taken to protect confidential information.

As a rule, never take identified patient data offsite from a practice. Electronic data are particularly difficult to secure, especially in the era of cloud computing.

Any data transmitted to or stored on your computer, tablet, or laptop should be deidentified with all personal health information PHI removed. A key code connecting patient PHI, including medical record number, to data you maintain on your computer or any that you are transporting offsite will need to be created to allow you to reidentify data if needed.

This key code should be housed at the practice and never taken offsite. In addition, you will need to set the security on your laptop to require a password to access any practice information stored on it. Less than a decade ago, nine out of ten doctors in the US updated their patient files manually and retained them in colour coded files.

This report itself outlines the future landscape of the data collection method. Considering that EMRs are better accepted and adopted by clinicians, they provide a promising option for tapping into hitherto unavailable data.

Patient chart review studies were conventionally used to understand the burden of illness and patterns of care in hospitals or treatment institutes. However, this methodology is increasingly being adopted to cater to the data requirements associated with marketing authorization and risk management, which also includes the data on off-label medication use.

Pharmaceutical companies are more enticed towards these types of studies considering the research benefits, since they help generate significant insights from hitherto under-utilized resources. A chart audit is a part of a retrospective assessment that unravels the potential of healthcare data. Chart audit data exists in many forms: electronic databases, results from diagnostic tests, and notes from health service providers, to mention a few.

A chart audit is a popular methodology widely applied in many healthcare-based disciplines such as epidemiology, quality assessment, professional education and residency training, inpatient care, and clinical research, and valuable information can be gathered from study results for subsequent prospective studies [2].

Chart audits serve many purposes, from compliance to research to administrative to clinical [6]. They can be conducted on virtually any aspect of care ordinarily documented in the medical record. Sometimes, clinical practitioners get puzzled by various clinical processes that do not operate as expected. In such cases, chart audits help to identify problems immediately and rectify them [7]. The most important use of a chart audit is to measure the quality of care so that it can be improved Figure 1.

Strong scientific evidence should be available to select the therapeutic area [8]. The criteria must be outlined precisely, with specific guidelines [9]. Sample size calculations must account for all the available data, funding, support facilities, and ethics of the patients subject to research [10]. This will increase the data accuracy and the study can be completed in time. The collected data can be quantitative or qualitative, and the data sources can be many.

The researcher must consider how the data will be used, and make sure the information is presented as per the study protocols [11]. Chart audits usually play a major role in quality improvement. They can determine how frequently a specific treatment is offered or declined in a practice. If the treatment is not offered as suggested, then there are opportunities to improve the whole setup by identifying the crucial gaps [12]. Thus, they are a valuable tool to capture varied clinical information.