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Medical Chart Review Form Template

Create an Efficient Medical Chart Review Process

Struggling to effectively assess patient records? This medical chart review form template is designed for healthcare professionals seeking to standardize evaluations and enhance patient care. With features that simplify data collection, ensure thorough documentation, and promote compliance with privacy regulations, you can easily track patient history and treatment plans, improve record accuracy, and save valuable time. Discover how effortless chart reviews can be with this accessible and user-friendly template.

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Your full name
Organization or practice
Role or title
Email
Phone
If Other, please specify
Your relationship to the patient or record holder
Treating provider
Referring provider
Payer or plan reviewer
Internal QA or compliance
Research team
Legal representative
Patient or self
Other
Please Specify:
Patient full name
Date of birth
Medical record number (MRN) or patient ID
Facility or location of care
EHR system or records platform (e.g., Epic, Cerner)
Dates of service to review - From
Dates of service to review - To
Provider(s) of record for the period requested
If Other review type, please specify
Specific questions or focus areas for the reviewer
Chart identifiers or case numbers (if applicable)
Review type or purpose
Coding accuracy
Clinical quality
Medical necessity
Risk adjustment (HCC)
Utilization management
Research/IRB
Legal/forensic
Peer review
Other
Please Specify:
Permissible basis to access PHI (select all that apply)
Patient authorization on file
Treatment/payment/healthcare operations (TPO)
De-identified data requested
IRB approval
Business associate agreement (BAA) in place
Court order/subpoena
Other
Please Specify:
Details (authorization number, IRB protocol, court order, or BAA reference)
Is a signed patient authorization available if required?
Yes
No
Apply minimum necessary standard and limit records to the requested scope
Yes
No
Sensitive categories to exclude from review (select all that apply)
None, include all applicable
Behavioral health/substance use
HIV/STD-related information
Genetic testing information
Reproductive health information
Other
Please Specify:
Destination details for delivery (e.g., secure email or fax number)
Additional instructions for transmission or handling
Preferred delivery method for results
Secure portal
Encrypted email
Fax
Phone call summary
Onsite review only
Priority
No deadline
Routine (5-7 business days)
Expedited (2-3 business days)
Stat (24 hours)
Target due date
Time zone
Best time to contact you
Morning
Afternoon
Evening
Any time
Signature (type full name)
Signature date
I attest that the information provided is accurate and that I am authorized to request this chart review in compliance with applicable laws and policies
Yes
No
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Paper art illustration depicting a medical chart review form template for FormCreatorAI article

When to use this form

This form helps you collect the right details for a thorough chart review across clinics, hospitals, and research projects. Use it when validating diagnoses, reconciling meds, or confirming documentation before a procedure or referral. For pre-op decisions, pair it with a Cardiac clearance request form. During hiring or workers comp cases, align findings with a Return to work discussion form to support safe duty plans. To fill gaps from intake, reference the Medical questionnaire form and confirm history, allergies, and symptoms. The result: cleaner records, faster reviewer decisions, and fewer back-and-forths with providers.

Must Ask Medical Chart Review Questions

  1. Which patient and identifiers are under review (full name, DOB, MRN)?

    This confirms you are reviewing the correct chart and protects patient privacy. Accurate identifiers prevent mix-ups and delays.

  2. What is the primary diagnosis and the specific decision this review should inform?

    A clear clinical target keeps the review focused and reduces unnecessary work. It aligns findings to the decision at hand, such as pre-op clearance or return-to-duty planning.

  3. Which encounter dates and care settings should we include in the review?

    Timeframe and setting define scope and help the reviewer pull the right notes. This avoids missing key events like ED visits, admissions, or rehab stays.

  4. What current medications, allergies, and recent changes are documented?

    Medication and allergy status drives safety, interactions, and contraindications. Capturing changes shows response to therapy and flags adherence issues.

  5. Which supporting documents are attached (labs, imaging, operative notes), and are any results pending?

    Attachments let reviewers verify evidence without chasing records, speeding up decisions. For reportable cases, keep details consistent with the Sexually transmitted infection report form.

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