Medical Record Audit Form Template
Streamline Your Medical Record Evaluation Process
Incomplete or inaccurate medical records can lead to significant compliance issues and impact patient care. This Medical Record Audit Form Template helps healthcare professionals ensure the quality and accuracy of your records, aligning with industry standards. You'll benefit from easy tracking of audit findings, streamlined reporting processes, and effective compliance with regulations, all while saving time and reducing errors. Explore this live template to gain confidence in your auditing practices.
When to use this form
Use this audit form when you need a consistent way to review patient charts for completeness, accuracy, and compliance. It helps clinic managers, coders, and quality teams spot gaps before payer reviews, accreditation visits, or provider onboarding. Run it after an EHR migration, during focused reviews of high-risk services, or as a monthly sample to track trends. Confirm that required authorizations accompany requests using the Medical record release form. For post-stay reviews, verify discharge documents and instructions against the Hospital patient release form. You can also include program-specific elements, such as medication monitoring or lab orders, to match your workflows. The result is cleaner documentation, fewer denials, and faster follow-up.
Must Ask Medical Record Audit Questions
- What date range, encounter types, and departments are in scope?
Defining scope keeps your sample representative and your findings comparable over time. It prevents reviewers from pulling in out-of-scope visits that skew results.
- Are patient identifiers, allergies, consents, and clinician signatures present and current?
Missing basics cause claim edits, safety risks, and privacy issues. Verifying currency reduces rework and speeds release of information.
- Do diagnoses, orders, and results align and support medical necessity?
When orders and results trace back to the stated diagnoses, coders can defend the claim and quality reviewers can validate care. If orders are missing, reference your process and attach the Medical requisition form to close the loop.
- Are discharge summaries, follow-up plans, and patient instructions complete and timely?
Strong discharge documentation supports continuity and reduces readmissions. Timeliness shows compliance with policy and payer rules.
- For controlled substances or high-risk care, is required monitoring documented?
Documented monitoring shows adherence to standards and protects patients. Capture evidence such as lab results using the Urine drug screen form when your policy requires it.
More Forms
- 100% Free - No Catches
- Collect Responses Today
- Tailor to your Look & Feel